Family-Focused Prevention and Early Intervention of Substance Use in Pediatric Primary Care Settings

Abstract

Prevention of substance misuse and substance use disorders is a national public health priority. The home environment can represent risk or protective factors for development of substance misuse. Children in homes with caregiver substance use are biologically, developmentally, interpersonally, and environmentally vulnerable to substance misuse and associated consequences, making it necessary for substance use prevention to focus on families early. Children and families who are minoritized, marginalized, and disenfranchised experience disproportionate consequences of substance use, through experiences of poverty, racism, trauma, and the built environment. Strengthening protective factors in early childhood by improving the health of caregivers and supporting the caregiver-child relationship can have enduring benefits over the life course. Pediatric primary care practices are an important setting for adopting a family-focused approach to prevention and early intervention of substance use. By engaging families early, identifying substance use in the family and household, recognizing the intersection of social needs and substance use, providing culturally tailored, trauma-informed, evidence-based care, and advising and supporting families on ways to minimize substance-related harm, pediatric care providers can play an important role in preventing substance use and substance-related consequences to children and families. Pediatric care providers are ideally suited to deliver prevention messages in a nonstigmatizing manner and serve as a conduit to evidence-based, family-focused intervention programs.

Surveillance estimates show a continued decline in the prevalence of substance use among youths in the United States (1). This trend is encouraging; however, recent decades have seen monumental shifts in the substance use landscape. Changes in the availability, potency, and delivery of substances have had an enormous impact on youths and families. Medicalization and legalization policies have changed the availability of cannabis, giving rise to increases in adult use and decreases in perceptions of cannabis-associated risks among adolescents (2). Rates of cannabis use disorder are increasing among young adults; however, treatment for cannabis use disorder is the lowest in this group (3). Fentanyl has overtaken the opioid drug supply, which has led to unprecedented rates of fatal overdose. Drug overdose and poisoning is currently the third leading cause of death among children and adolescents in the United States (4). Despite historic gains in reducing youths’ cigarette use, rates of nicotine vaping are now on par with alcohol and cannabis use among youths (1). Adolescent vaping is a risk factor for use of alcohol, cannabis, and cigarettes as well as polysubstance use (5). These and other concerning substance use trends emphasize the importance of centering efforts on prevention and early intervention of substance use in order to be responsive to current trends and use patterns.

Substance Use Is a Pediatric Disease

Substance misuse is a pediatric health problem, which must be addressed in a developmental context. Substance use disorders frequently begin in adolescence or even childhood. Early initiation of substance use has consistently been shown to be a risk factor for development of a substance use disorder. Most individuals in substance use treatment (74.0%) began substance use at age 17 or younger, with 10% initiating use at age 11 or younger (6). Although adolescence is the developmental period typically targeted for substance use prevention, early childhood experiences can affect a child’s substance use trajectory. Addressing peer affiliations and risk perception are important in adolescence, yet there are other factors in early life, such as parenting practices and qualities of the home environment, including some that are beyond the families’ control, that are known to impact vulnerability to substance use (7). Early intervention has the potential to bolster protective factors and mitigate risk factors for substance use.

Family Context for Substance Use

The family ecosystem influences and is influenced by substance use and substance use disorder. Caregiver functioning and behaviors can represent risk or protective factors for development of substance use in children. Caregiver substance use is an important context when considering prevention and early intervention for children. National surveillance data estimate that one in four children are exposed to alcohol misuse or alcohol use disorder in their household (8). Rates of both cannabis and opioid use during pregnancy have increased (9, 10). Recent survey data have shown that the number of children who lost a parent to drug overdose has rapidly increased over the past decade and emphasizes the multigenerational impact of the overdose crisis (11). Children in homes in which caregivers have substance use disorders are biologically, developmentally, interpersonally, and environmentally vulnerable to substance misuse and associated consequences, which makes it necessary to focus on families early in substance use prevention. This is consistent with pediatric medical home models that move away from exclusively child-focused interventions to that of family health, and recognize that sustained child emotional and behavioral health relies on their caregivers’ emotional and behavioral health in order to achieve a healthy family environment (12).

Role of Primary Care

Pediatric primary care practices are an important setting for prevention and early intervention of substance use. Pediatric care providers (PCPs) play a vital role in preventing substance use–related consequences by identifying and addressing substance use early in adolescence. However, identifying risks in the family and home environment as well as promoting healthy behaviors create opportunities for even earlier intervention. Pediatric primary care settings are ideally suited for adopting a family-focused approach to substance use prevention and early intervention, because promoting health of the caregiver is promoting health of the child and family. Inquiring about family well-being and the home environment is consistent with the Bright Futures Guidelines that recommend that PCPs assess caregiver tobacco use, maternal depression, intimate partner violence, parental immunization status, and family planning (13). The American Academy of Pediatrics has long recognized the importance of universal screening for family history and current caregiver substance use at well-child visits as a part of the recommended pediatric provider competencies that also include an evaluation of medical, psychiatric, and behavioral manifestations of childhood exposure to family substance use; recognition of the potential benefit of early intervention for children and families; communication of appropriate concern to families and offering support and follow-up; directing caregivers who screen positive for substance use to resources; and determining whether family resource needs and services are appropriate (14). Prevention is the foundation of pediatric primary care and addressing substance use in the family and household is a natural extension of this role. PCPs are not expected to diagnose, manage, or treat caregiver substance use; however, providing substance-informed and family-focused care maximizes the ability to prevent harms associated with substance use in the family and household.

Longitudinal Relationship

The long-term engagement with patients and families and the coordination of their care is the hallmark of effective primary care. The longitudinal relationship provides an opportunity for PCPs to look upstream to address risk factors early and to optimize the child’s home environment. PCPs are viewed as trusted resources and are skilled at communicating with families in a nonstigmatizing manner (15). Screening for family history provides the knowledge that some children may be at higher risk for substance use and require a closer eye from their PCP. Ray and colleagues (16) found that children from families affected by substance use disorders have greater health care needs, including greater odds of diagnoses of ear infection, asthma, attention-deficit hyperactivity disorder, headache, trauma, and depression, in addition to substance misuse. During adolescence, living in a home with caregiver substance use raises concerns about access to alcohol and other substances, which increases the risk of use for adolescents. PCPs have the opportunity to provide health risk appraisal, prevention counseling, and caregiver-focused anticipatory guidance that are related to these vulnerabilities throughout childhood and adolescence (17). From the earliest engagement with caregivers, PCPs can prevent and/or minimize the harms of substance use.

Disproportionate Consequences of Substance Use

Vulnerability to substance use and the adverse consequences of use are experienced disproportionately by minoritized, marginalized, and disenfranchised children and families. Despite similar rates of substance use, Black and Latinx youths are more likely to experience harmful outcomes of substance use and are less likely to receive evidence-based treatment (18, 19). Although Black youths use cannabis at similar rates as White youths during adolescence, there is evidence of a cross-over effect, in which Black adults experience higher rates of cannabis use disorder in adulthood (20–22). Stemming from the federal war on drugs, Black youths and adults experience disproportionately worse legal consequences of cannabis use (i.e., higher arrest and confinement rates) (23–25). Incarceration not only affects the individual and family, but also disparate incarceration rates have significantly affected Black communities (26). Indigenous youths bear a disproportionate burden of substance use and substance use disorders, having the highest rates of alcohol, cannabis, and opioid use, and experiencing the highest rates of opioid overdose (https://aspe.hhs.gov/reports/substance-use-suds-race-ethnicity) (27–29). These inequities are rooted in historical traumas that include exploitation, dehumanization, and decimation of Indigenous peoples that are a result of settler colonialism (30). Past-year substance use disorder was highest among American Indian or Alaska Native (24.0%) and Multiracial people (21.8%), followed by Black or African American (18.4%), White (17.6%), Hispanic or Latinx (17.4%), and Asian people (9.0%) (6). Compared with White youths, minoritized youths are less likely to receive high-quality, evidence-based behavioral health care (31).

Social Determinants of Health Drive Risk for Substance Use

Traditional models of addressing substance use in pediatric primary care do not recognize the impact of social inequities on substance use outcomes or include evidence-based strategies to explicitly address socioeconomic, racial, and environmental risk factors. Understanding how social determinants of health (SDH) affect the family ecosystem is critical to providing effective family support and early intervention.

Historical, social, political, and economic forces have created a vulnerability to individual, environmental, and societal factors that drive health disparities. SDH are the conditions in which people live, grow, learn, work, and play. These encompass the health-related features of the built environment, including walkability, access to transportation, healthy food, clean air and water, as well as access to and quality of health care and education. SDH influence individual socioeconomic factors, including poverty, food and housing insecurity, and lack of access to health care, as well as trauma exposure such as experiences of community violence (32). Racism is a SDH that operates at the individual, interpersonal, community, and societal levels; has a vast impact on the health of children and families; and is a significant driver of health inequities. Experiences of poverty, the built environment, racism, and trauma affect mental health and substance use.

Poverty often intersects with other SDH, such that children who live in poverty are more likely to live in communities with collective conditions of economic hardship and a broader social and environmental context, including high rates of violent crime, physical disorder, poor educational and employment opportunities, and reduced access to health-promoting resources (33). Research has found neighborhood disadvantage to be associated with alcohol use, particularly during adolescence, and living in neighborhoods that have high rates of violent crime and poverty to be predictors of substance use trajectories (34–37). Youths who experience community disadvantage have elevated rates of cannabis use disorder and adverse social consequences that persist into adulthood (20, 22, 38–43). Living in poverty has been shown to negatively influence adolescent drug use, including use of cocaine, heroin, and stimulants (44).

Physical aspects of the neighborhood, including vacant homes, broken windows, vandalism, and discarded drug paraphernalia, are associated with youths’ increased use of cannabis (45). The built environment may also increase the availability of substances. Alcohol and cannabis outlet density is known to be concentrated in economically disadvantaged communities (46, 47). Youths living near cannabis dispensaries are more likely to report cannabis use and lower perceived harm from use of cannabis (48). Similarly, living near an alcohol dispensary is associated with heavy alcohol use among adolescents (49). In contrast, youths and families living in under-resourced communities have less access to early intervention and treatment of substance use.

The health of Black, Indigenous, and other people of color is affected significantly by racism, which is a unique context that must be explicitly considered when addressing health disparities (50, 51). Structural racism has disproportionately exposed minoritized youths and families to adverse SDH. Indigenous Americans have experienced historical traumas of child removal and current traumas of the Missing and Murdered Indigenous Peoples crisis, and are more likely to experience environmental exposure disparities and inequities in health care on the basis of land allocation (52, 53). Black youths are significantly more likely to grow up in economically distressed neighborhoods and experience multiple marginalized identities on the basis of race and socioeconomic status (54). Black, Latinx, and Indigenous youths are three times more likely to live in poverty than White or Asian youths (55). Minoritized youths also grow up with higher rates of parental unemployment and lower household wealth (56). Children and families from racial-ethnic minority groups are more likely to experience over-policing, which leads to disproportionate criminal justice and child welfare system involvement as well as disciplinary action in schools (26, 57, 58). Racialized neighborhoods are also overexposed to drug markets and social networks in which substance use is normalized (59). In a qualitative study, Black adolescents viewed cannabis use as a response to neighborhood disadvantage, including neighborhood violence, poor-quality schools, and lack of access to opportunity (60).

Minority stress frameworks explain the relationships between additional stressors that are uniquely experienced by people of a minority status (61–63). Youths experience perceived racial discrimination as acute forms of stress (64). Among Black youths, experiences of racial discrimination have been associated with cannabis use in adolescence and adulthood (65–67). Experiencing neighborhood disadvantage is also associated with higher perceived stress and is stronger in those with greater substance use involvement (68). Youths with greater life stressors may be more likely to use cannabis for stress-coping purposes (69). Stress increases vulnerability to addiction through neurobiological pathways—the acute effects of cannabis are more rewarding and reinforcing when a person is experiencing stress (70). Black youths who endorsed more coping-motivated cannabis use reported a greater number of cannabis use–related problems (71).

The collective experiences of adverse SDH have harmful impacts on child and family well-being, including experiences of trauma. Trauma can be intergenerational (53). Trauma encompasses numerous experiences that cause emotional and/or physical harm. Toxic stress occurs after experiencing prolonged adversity, which leads to persistent activation of the stress response and disruption of the developing brain (72). Sources of trauma can originate from outside the home, such as community violence, or take place within the home. Traumatic experiences that take place during childhood, such as emotional, physical, or sexual abuse, domestic violence, parental incarceration, and parental substance use are adverse childhood experiences (ACEs). Surveillance studies have found that ACE exposures are more prevalent among those living in poverty and among Black, Latinx, and multiracial respondents (73). In the United States, drug policies have inflicted a significant and disproportionate impact on Black and Brown communities, including criminalization and incarceration, which can result in lifelong criminal records and disrupt access to employment and resources that support the health and well-being of families (74). These overwhelmingly punitive responses may limit the willingness of minoritized families to be forthcoming about substance use.

Caregiver substance use is the most prevalent ACE, which often co-occurs with other forms of household dysfunction, including witnessing intimate partner violence and parental incarceration (75). Experiencing multiple ACEs has a dose-response relationship with harmful behaviors and health conditions in adulthood, including alcohol and other substance use disorders (75). Children in homes with caregiver substance use are more likely to experience poverty, housing instability, caregiver abuse and neglect, poor mental health, and chronic health conditions (16, 76, 77). Caregiver trauma may affect the ability to provide a safe, stable, and nurturing environment for the child.

Prevention and Early Intervention

Prevention, early intervention, and treatment strategies are employed depending on the patient’s level of risk. Universal prevention is designed to reach everyone in a given population without regard to individual risk factors. Selective prevention is targeted to individuals with defined risk factors for the development of substance misuse. Indicated prevention is aimed at individuals who are experiencing early signs of substance misuse but are not diagnosed as having a substance use disorder. Within each level of intervention, there are levels of involvement by the PCP, which range in intensity depending on practice resources (17).

Universal Screening for Substance Use in the Family or Household

An important and often overlooked aspect of universal prevention is to consider the family environment. PCPs can play a vital role in identifying and addressing factors in the home environment early in childhood that will help to reduce long-term risk for substance use and other related outcomes. Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based practice to identify and address substance use. Incorporating family screening (F-SBIRT) broadens this to a family-focused approach (17). Screening for substance use in the family and household at initial and subsequent encounters with a family offers the ongoing opportunity for early and impactful intervention. Despite PCP fears of offending families, caregivers have been found to overwhelmingly endorse universal screening for substance use and substance use disorder in the family or household during well-child visits, and acceptability did not differ for caregivers with and without substance use in the family and household (78, 79).

Routine screening may be incorporated into a comprehensive review of family history or alongside questions about the home environment (80). A universal approach is critical to overcome the stigma that is associated with seeking care for substance use disorders and disclosure of the family environment. Although not a validated instrument, asking caregivers “Do you have concerns about someone in your household who is drinking alcohol or using drugs?” asks about all members of the household who may care for the child inclusive of, but not excluding, just the parent presenting the child for care. This opens the conversation for caregivers to define concerning substance use and for the PCP to obtain more detailed substance-specific information that could inform guidance. Fear of punitive responses, including child custody loss, could limit caregiver disclosure; however, PCPs can raise the issue and create a safe environment so that the family may be more comfortable about disclosing concerns at future encounters. To ensure successful screening, PCPs must feel confident in navigating safety assessments if substance use in the home is disclosed (80). Guidance from the United Nations states that children should be protected from the use, production, and trafficking of illicit drugs, and thus screening opens opportunities for prevention of abuse and neglect (81). However, caregiver substance use alone is not sufficient cause for the involvement of child protective services. PCPs are experts at communicating with caregivers in a supportive and nonjudgmental manner in order to advance the best interest of the child. A negative family substance use screen provides an opportunity for anticipatory guidance regarding safe medication management. Medications commonly found in medicine cabinets may pose harm to children and adolescents. Clear guidance from PCPs to lock medications out of sight and dispose of unused controlled medications can protect young children from accidental ingestion as well as curious adolescents from experimentation (82).

Screening for SDH in the Family or Household

Parents and caregivers who are navigating adverse SDH may have fewer physical and emotional resources to mitigate the adversities and toxic stressors experienced by their children early in life (31). PCPs should be aware that exposure to family substance use, trauma, poverty, and marginalization may present in various ways and keep these diagnoses on the differential of many presenting symptoms (83). Screening for SDH during well-child visits, as recommended by the American Academy of Pediatrics, can serve to inform care for patients and families and has been shown to improve outcomes (56, 84). As with screening for substance use, the universal implementation of standardized screening tools can reduce provider bias (31). There are several tools designed to assess social needs in pediatric settings, some that are available in multiple languages (https://sirenetwork.ucsf.edu/tools-resources/resources/screening-tools-comparison/peds). In lieu of standardized instruments, PCPs can conduct thorough history taking by utilizing practical advice and guidelines for rendering trauma-informed care in medical settings (83, 85). Experiencing adverse SDH and socioeconomic factors may hinder care engagement, including a reduced ability to attend appointments and adhere to treatment plans (86). Primary care practices can align the structure and process of care to meet the needs of the families they serve (86). PCPs can maintain a list of resources to meet basic needs (i.e., shelters, food banks), referrals to assist with enrollment in public benefits, and ensure that practice policies minimize barriers to care, including accommodating late arrivals, rescheduling no-shows without a fee, extending office hours to accommodate inflexible work schedules, and offering telehealth for follow-up care when possible (83). Practices that have greater resources can offer multidisciplinary care coordination, including home-visiting programs, or host onsite social workers or patient navigators to assist in care engagement and management (83, 86).

It is important, however, to not view youths and families solely from a deficit lens, but to recognize their assets as well. Studies suggest that cumulative ACEs do not impede recovery from substance use disorders if positive childhood experiences (PCEs), particularly in family and community contexts, are in place (87). Clinical assessments should identify and promote PCEs, such as caregiver support, academic achievements, connectedness, and a safe environment, that can facilitate recovery (87). The American Academy of Pediatrics recommends that PCPs integrate positive youth development approaches and incorporate strategies such as raising resisters during anticipatory guidance, in order to promote a strong, positive racial-ethnic identity, which has been shown to be protective against the negative effects of experiencing racism (56).

Universal Prevention

The family and home environment has the most direct influence on child development, and the quality of the parent-child relationship is a critical factor for adolescent substance use. Programs that strengthen the caregiver-child relationship and support caregivers’ ability to provide a safe and stable home for their children may be powerful substance use interventions. There are several evidence-based universal prevention programs that span early developmental periods, from infancy to elementary school (88). Engaging with families early provides the opportunity to reduce risk factors and increase protective factors during salient developmental periods, which can result in positive long-term effects (88). Interventions work by addressing modifiable risk factors, which can include features of the child’s social and physical environment. Intervening in early childhood can address internal and external risk and protective factors and have a broad impact on a host of outcomes, such as academic achievement and self-regulation, which serve to prevent substance misuse and to promote healthy development broadly.

Evidence-Based Universal Family-Focused Prevention

The goal of universal programs is to support developmentally appropriate skills for children (e.g., social skills, emotion regulation) and for their caregivers (e.g., limit setting, communication) (88). PCPs can refer caregivers to programs in the community or host programs onsite, depending on practice resources (17). Multiple universal prevention programs have been adapted for implementation in different cultures and family environments and to improve accessibility. The Guiding Good Choices program has been adapted to support transracially adopted youths and their caregivers by incorporating trauma-informed care and adoption-specific content (89). The Familias Unidas, Bridges/Puentes, and adapted Brief Strategic Family Therapy programs have been tailored to effectively address adolescent substance use in Latinx communities by including cultural values as well as issues that are related to the Latinx experience, such as immigration and acculturation (90). For many of these programs, transportation, meals, and babysitting are provided to reduce barriers to family engagement (91). Leveraging technology to deliver universal prevention programs may also have implications for improving access for marginalized families and may facilitate implementation in primary care settings (80). A DVD or online video version of Strengthening Families Program has been found to be cost-effective, and online adaptation of Guiding Good Choices is being evaluated in primary care settings (91, 92).

Parental supervision has been found to be protective against harmful alcohol use trajectories from adolescence to young adulthood, even in the context of neighborhood disadvantage, and parental support decreases risk of drug use despite living in poverty (37, 44). These findings emphasize the need for programs that educate and support parents in order to promote healthy parent-child bonds, which protect children from some of the adverse impacts of families’ socioeconomic status.

Selective Prevention

Selective prevention strategies are tailored to meet the needs of children who have defined risk factors for the development of substance misuse. Family history of substance use is an indicator that a child is a candidate for selective prevention. A positive screen that identifies concerning substance use in the family or household offers the opportunity for PCPs to view the health care needs of the child using a substance-informed lens, increase follow up and monitoring, and engage the caregiver on the home environment. If opioids are prescribed to family members or there are any opioids present in the home, naloxone should be prescribed, and family members should be educated on its use (82). PCPs are not expected to provide caregivers with a diagnosis or determine type or level of care (17). However, PCPs can engage with caregivers to discuss the potential impact of caregiver substance use on families, recommend behaviors to help mitigate child risk, and assess caregiver interest in referral to treatment resources and/or parenting programs (80).

Experiences of marginalization that result from economic or social status, identity, system involvement, or other factors affect not only substance use, but also a wide range of other health risks and outcomes. Pediatric primary care settings are well-positioned to identify and address both substance use and adverse SDH in the home environment. Delivering care utilizing a trauma-informed framework allows PCPs to identify, acknowledge, and manage the effects of trauma while being sensitive to the cultural context of trauma experiences and responses (53, 85). Children are protected when their caregiver can provide support and buffer stressors. Trauma-informed approaches that integrate social and cultural factors related to intergenerational trauma and discrimination have resulted in better engagement and improved mental and behavioral health outcomes for minoritized children (31). Understanding the wholistic picture of the home environment facilitates a recognition of resource constraints (e.g., financial, nutritional, housing) when counseling and advising on health conditions and behaviors.

There remains a need for evidence to guide optimal PCP response to positive family substance use history. At a minimum, PCPs can provide families with the Substance Abuse and Mental Health Services Administration’s National Helpline (https://www.samhsa.gov/find-help/national-helpline). Having a resource list of available treatment programs and the insurance carriers they accept for parent referral may help overcome barriers and facilitate the admission of family members into care. Linking a caregiver to treatment may be one of the most impactful actions, because treatment for the caregiver is also prevention for the child. The PCP can also refer the child and family members to recovery support and/or family-focused prevention programs as appropriate (17).

Caregiver-Focused Selective Prevention Programs

Caregiver substance use during childhood is associated with negative parent-child relationships, mental health and internalizing problems, cognitive deficits and poor academic outcomes, and conduct and behavioral problems (93–95). However, protective factors at the individual, family, and environmental levels can build resilience and reduce the likelihood of negative outcomes (95). Caregiver-focused prevention programs that address parenting behaviors, mental health, and/or substance use have been effective at improving child outcomes (80). Programs that integrate treatment of caregiver substance use with parenting skills training are more effective than parenting or treatment programs alone in improving caregiver outcomes (96). However, current programs that address caregiver substance use rely on referrals from child protective services (e.g., The Sobriety Treatment and Recovery Teams, Multisystemic Therapy—Building Stronger Families) or addiction treatment (e.g., Fathers for Change, Dads “n” Kids) (97–99). These programs address the specific concerns of caregivers who use substances, such as providing intensive care coordination, and are effective in reducing caregiver substance use and intimate partner violence, which improves caregiver emotion regulation and parenting skills. However, they are limited in that they exclude the estimated 46.3 million Americans with a substance use disorder who are not in treatment, many of whom are parents, and/or miss opportunities to engage families prior to child protective services involvement (6). PCP screening and referral may be one nonpunitive opportunity to involve more families in these evidence-based programs.

Opportunities for Primary Care

Pediatric primary care can extend the reach of both universal and selective parenting programs. The Family Check-Up, Strengthening Families Program, Familias Unidas, and Guiding Good Choices have all been adapted for the primary care setting and are effective options for primary care–based treatment referral options for PCPs who are looking to engage caregivers in prevention and early intervention (80). eHealth Familias Unidas Primary Care is an online adaptation of Familias Unidas that includes facilitated caregiver-adolescent video conference sessions that are designed to improve accessibility for Hispanic immigrant caregivers and their children (100). Few programs have been explicitly evaluated with caregivers who use substances; however, an online adaptation of The Family Check-Up for caregivers with opioid use that includes modules on substance use within the parenting context is currently being evaluated (101).

A key opportunity to advance family-focused prevention and early intervention is to grow a workforce that is more representative of the communities being served (102). In order to overcome barriers, pediatric residency programs must develop competencies in screening, early intervention, and consultation with addiction medicine specialists (17). Medical training should also emphasize the intersection of SDH and substance use. To address substance use disorders effectively requires a focus on the needs of children and families. For many, the problem is compounded by the significant racial and economic health disparities that exist within their affected communities. Patient navigators—community health workers who often have lived experience with addiction themselves—can help with recovery support services, including assistance with navigating care systems, assessing barriers to follow up or adherence to the care plan, and maintaining patient engagement in substance use disorder treatment, and serve as an essential extension of the clinical care team (103). The Prevention Technology Transfer Center (PTTC) Network offers an extensive set of resources that can help PCPs understand the impact of culture and identity in prevention efforts (https://pttcnetwork.org/equity). Pediatric primary care models that enable family-focused prevention and early intervention, strengthen care coordination, and efficiently leverage behavioral health staff should be further developed and expanded (102). In parallel, reimbursement models that incorporate SDH and patient panel complexity calculations are needed and may be particularly important in pediatrics for substance use disorder prevention (104).

Conclusions

The longitudinal and trusted relationship with children and families makes pediatric primary care a compelling setting for implementing family-focused substance use prevention and early intervention. PCPs play an important role in preventing substance use and substance-related consequences by engaging families early; identifying family substance use; providing culturally tailored, trauma-informed, evidence-based care; and advising and supporting families on ways to minimize substance-related harm. PCPs can recognize inequities and employ approaches that address SDH and socioeconomic conditions that pose barriers to family health. There are practical and achievable actions all PCPs can take to support caregivers. PCPs can also be a conduit to evidence-based, family-focused intervention models. Bolstering protective factors in early childhood by improving the health of caregivers and strengthening the caregiver-child relationship can have enduring benefits over the life course.