Intersecting stigma of substance use and child welfare system involvement: Understanding stigma drivers, experiences, and outcomes from a socioecological perspective

Abstract

Background

Substance use in parents is a common reason for child welfare system involvement (CWS). Stigma associated with substance use and disorders (SU/D) continues to negatively impact individuals; however, less is understood about the intersecting stigma of CWS involvement and SU/D. The current study seeks to understand parents’ experiences of stigma related to SU/D and CWS involvement as well as the drivers and consequences of stigma at multiple socioecological levels using the Health Stigma and Discrimination Framework.

Methods

Qualitative data analysis was conducted on semi-structured interviews with N = 31 Child Welfare System (CWS) personnel (90.3 % female; 96.8 % White, Non-Hispanic), N = 28 SU/D service providers (85.7 % female; 67.9 % White; 89.3 % Non-Hispanic), and N = 28 parents (89.3 % female; 78.6 % White; 89.3 % Non-Hispanic) with a current or recent CWS case due to SU/D.

Results

Stigma drivers included a lack of understanding of SU/D at interpersonal, community, and organizational levels; negative stereotypes of parents with SU/D involved in CWS (seen as dishonest, unmotivated, poor parents); community neglect of SU/D; negative attitudes towards SU/D medications and harm reduction; and CWS policies unsupportive of SU/D. Parents described experiences of stigma by CWS and the healthcare system, their communities, and loved ones, leading to social isolation and hesitancy to engage in services. Consequently, stigma impacted SU/D service availability, housing/employment policies, and CWS practices, further negatively impacting parents.

Conclusion

Parents with SU/D and involved in CWS have unique experiences of stigmatization related to both SU/D and CWS involvement. Findings point to multiple targets for stigma reduction at different socioecological levels.

Highlights

• •Intersecting stigma related to substance use and child welfare involvement impacts parents.
• •Stereotypes, substance use service stigma, community ignorance, and child welfare policies drive stigma.
• •Limited substance use services, child welfare policies, and public policies are results of stigma.
• •Stigma is perpetuated by factors at multiple levels from individuals to public policy.

1. Introduction

1.1. Background

Substance use and substance use disorders (SU/D) remain a prevalent public health issue and the child welfare system (CWS) has been particularly impacted by SU/D. It is estimated that up to two-thirds of CWS cases involve parents who use substances (ParWUS; (Ghertner et al., 2018, Radel et al., 2018), which is concerning as cases involving ParWUS are associated with worse outcomes, including out-of-home foster care placements, extended case lengths, and a higher likelihood of termination of parental rights compared to cases not involving SU/D (Akin et al., 2015, Lloyd et al., 2017, Steenrod and Mirick, 2017). Families involved in CWS are required to engage in multiple services to prevent risk of repeat maltreatment, and ParWUS are typically required to complete SU/D treatment, in addition to other services to prevent repeat maltreatment (Saldana et al., 2021); however, it is estimated that less than 20 % of ParWUS complete required SU/D treatment (Choi and Ryan, 2006, Steenrod and Mirick, 2017). Multiple barriers to treatment completion exist including comorbid health issues, parental responsibilities, lack of access to treatment, and, importantly, stigma (Bosk et al., 2019, Lin et al., 2020).

SU/D remains one of the most stigmatized health conditions (Krendl and Perry, 2023, Perry et al., 2020). People who use substances experience stigma from families, the larger community, and healthcare systems (Can and Tanrıverdi, 2015, Cheetham et al., 2022, Perry et al., 2020). Stigma is a major barrier to seeking treatment, establishing social support, maintaining housing and employment, and has negative impacts on mental and physical health (Crapanzano et al., 2018, Major et al., 2018). While all individuals who use substances are at risk of being stigmatized, there is evidence that ParWUS experience more stigma compared to non-parents, in particular dealing with stereotypes of being an unfit parent due to their SU/D; such stereotypes – as well as fear of possible reports to CWS – are a major barrier to ParWUS seeking treatment (Stringer and Baker, 2018).

Further compounding stigma that ParWUS experience is evidence for the stigma associated with CWS involvement. Parents involved in CWS face stigma and discrimination from the public and CWS related to negative views of them as parents that results in guilt and shame (Bekaert et al., 2021, Dir et al., 2025). Given the potential for multiple sources of stigma that ParWUS in CWS can experience (Kenny and Barrington, 2018) and the potential negative impacts, more research on these intersecting stigmas is warranted.

The Health Stigma and Discrimination Framework (HSDF; (Stangl et al., 2019)) is one such framework that may be useful for better understanding stigma associated with SU/D and CWS involvement because it recognizes there are often intersecting stigmas (i.e., CWS involvement, SU/D) that can compound individuals’ experiences of being stigmatized. The HSDF considers how multiple socioecological levels – from individual attitudes to public policy – contribute to stigmatization; it posits that drivers/facilitators at different socioecological levels (i.e., health policy, individual stereotypes) and intersecting stigmas (e.g., gender, race) lead to stigma marking, or the process by which stigma is attributed to individuals. Stigma marking results in stigma experiences (e.g., rejection by others) and practices (e.g., stigmatizing language), which in turn results in outcomes for the stigmatized populations (e.g., lack of access to care) and the larger socioecological context (e.g., organizational policies) which may perpetuate or combat stigma (see Fig. 1). For example, while the HSDF has not been applied to SU/D, there is extensive research on HSDF constructs. Common drivers/facilitators of SU/D stigma include stereotypes of individuals with SU/D as self-destructive, dangerous, or unreliable (Nieweglowski et al., 2018) and perceptions of SU/D as a moral issue rather than a chronic disease (Yang et al., 2017). Stigma practices and experiences include use of stigmatizing language (e.g., “addict”) and social distancing from those with SU/D (Kulesza et al., 2013, Yang et al., 2017). Consequences of stigma for those stigmatized include limited social support and avoidance of seeking treatment; consequences – and further reinforcers – of stigma at the system-level include underfunding of SU/D treatment, and organizational policies such as those related to SU/D in housing and employment (Crapanzano et al., 2018, Major et al., 2018). Application of the HSDF to SU/D stigma and the intersecting stigma of CWS involvement facilitates identification of targets and needed interventions to reduce stigma (Andersson et al., 2020).

Fig. 1.

Health Stigma and Discrimination Framework: Parents with SU/D Involved in CWS. Drivers and facilitators at multiple socioecological levels from the individual to public policy level include stereotypes and community beliefs about SU/D, and even policies that impact individuals with SU/D. These drivers and facilitators in turn lead to stigma manifestations, which include stigma practices, such as use of stigmatizing language and reinforcement of stereotypes, as well as stigma experiences at the individual, community, and organizational level. Further exacerbating these stigma manifestations is the intersecting stigma of being involved in CWS (driven by beliefs of individuals involved in CWS as “bad parents” and undeserving of being a parent). Stigma practices and experiences result in outcomes which impact ParWUS (e.g., lack access to adequate treatment, guilt, shame, social isolation), and outcomes at the larger community, system, and organizational levels (e.g., housing/employment policies specific to people with SU/D, CWS policies, lack of appropriate SU/D treatment options).

1.2. Current study

The current study seeks to conceptualize sources of stigma, stigma experiences, and impacts of stigma on ParWUS in CWS and the larger socioecological system using the HSDF as a conceptual framework. We specifically seek to explore the intersection of multiple socioecological levels, including CWS, SU/D service systems, and communities, and how these serve to perpetuate and/or combat stigma by exploring unique perspectives from ParWUS, CWS personnel, and SU/D service providers through qualitative interviews.

2. Methods

2.1. Sample and procedures

CWS personnel (N = 31); SU/D service providers (N = 28); and parents (N = 28) who were currently or recently (within 5 years) involved with CWS and SU/D treatment from a Midwest state were recruited to complete semi-structured phone or video interviews as part of a larger study exploring the barriers and facilitators parents face in engaging in SU/D treatment and navigating CWS (see Dir et al., 2025) for additional study procedures). Purposive sampling was used to ensure a heterogeneous sample of participants with respect to demographic variables and geographic region (see Table 1). All study activities were approved by the affiliated university’s Institutional Review Board.

Table 1.

Sample characteristics.

	CWS Personnel (N = 31)	SU Providers (N = 28)	Parents (N = 28)
Demographics
Agea (M, SD)	33.2 (8.7)	40.3 (13.0)	32.5 (5.2)
Ethnicityb
Hispanic or Latino	1 (3.2 %)	--	3 (10.7 %)
Not Hispanic or Latino	30 (96.8 %)	25 (100.0 %)	25 (89.3 %)
Raceb
Black or African American	1 (3.2 %)	4 (16.0 %)	3 (10.7 %)
More than One Race	--	--	3 (10.7 %)
White	30 (96.8 %)	19 (76.0 %)	22 (78.6 %)
Unknown/Chose Not to Disclose	--	2 (8.0 %)	--
Gender
Female	28 (90.3 %)	27 (96.4 %)	25 (89.3 %)
Male	3 (9.7 %)	1 (3.6 %)	3 (10.7 %)
Unique counties represented	19	16	12
Region
Central	8 (32.0 %)	14 (50.0 %)	14 (50.0 %)
North	12 (48.0 %)	5 (17.9 %)	8 (28.6 %)
South	5 (20.0 %)	9 (32.1 %)	6 (21.4 %)
Rurality
Rural	5 (20.0 %)	1 (3.6 %)	6 (21.4 %)
Rural/Mixed	10 (40.0 %)	10 (35.7 %)	8 (28.6 %)
Urban	10 (40.0 %)	17 (60.7 %)	14 (50.0 %)
CWS & Provider Characteristics
Clinical Coordinator/Consultant	2 (6.5 %)
Case Management	25 (80.6 %)	7 (25.0 %)
Peer Recovery Coach		6 (21.4 %)
Therapist		4 (14.3 %)
Supervisorial/Directorial Role	4 (12.9 %)	11 (39.3 %)
Parent Characteristics
Out of home case (home removal)			26 (92.9 %)
Open case status			17 (60.7 %)
Primary Substance Usedb
Alcohol Only			1 (3.6 %)
Opioids Only			9 (32.1 %)
Stimulants Only			10 (35.7 %)
Stimulants & Opioids			6 (21.4 %)

Note.

^aN missing: 8 SU providers, 12 parents;

^bN missing: 3 SU providers, 2 parents

2.2. Measures: qualitative interview guide

Semi-structured interview guides were developed in collaboration with a Midwest state’s CWS birth parent advisory board (BPAB). Separate guides were created for each participant group and questions addressed (1) facilitators and barriers to engaging in SU/D services and navigating CWS; (2) individual, community, and organizational attitudes towards SU/D, people who use substances, and ParWUS in CWS (e.g., what are CWS views on SU/D?); and (3) experiences of stigma (see Supplementary Material for full interview guide). Demographics were also collected during screening and interviews.

2.2.1. Data analysis

Interview recordings were uploaded to NVivo for thematic analysis (Lumivero). Authors AD and BB developed a codebook through a priori categorization of research questions, inductive review of transcripts (Emerson et al., 2011), and development of codes according to HSDF constructs (see Table 2 for codes and descriptions, themes, and example quotes). Once consensus was reached on the codebook, authors completed focused coding. First, 10 % percent of the transcripts were coded independently by both AD and BB followed by consensus meetings to ensure consistency across raters and discuss discrepancies (Cofie et al., 2022, O’Connor and Joffe, 2020, Thomas and Harden, 2008). Following this, AD and BB coded the remaining transcripts independently and met to discuss and summarize coding findings (Braun and Clarke, 2022).

Table 2.

Codes, subcodes, and example quotes.

Code/Theme	Quote/Definition
Drivers/Facilitators	Factors (beliefs/attitudes, practices) at multiple environmental levels that contribute to or lead to stigma 'marking' (i.e., the application of stigma to individuals).
Beliefs about SU/D and addiction	“I think a lot of people don't understand recovery and substance use when it comes to that. I think they just think well, just stop using like it's that easy and they don't understand how it affects your chemical makeup and your brain and the physical addictions that you're gonna go through. They just think, well, if you are clean for a week or two, you should be fine and not understanding that the mental and physical or psychological aspect of it is gonna last a lifetime.” (CWS9)
	“They just think it’s something you can quit overnight, and you really can’t. You can’t wake up and say, ‘oh, I’m done.’” (Parent21)
	“It is a stigma because not enough people understand why people use.” (Parent29)
Stereotypes of ParWUS
Poor parents	“I think a lot of people they just like they don’t understand…You are a drug addict. You chose to do drugs instead of care for your kids.” (CWS27)
	“It's not that we don't love our kids when we're in addiction, it's that we just can't survive without that drug.” (Provider14)
Dishonest, mistrustful	“I think parents are often dishonest about their use and we'll screen them and, you know, ask before, hey, what's this gonna come up for? When was the last time you used? And then their screens aren't really matching what they're saying. You know, I haven't used in a month. Well, OK, you're positive. So, you're lying to me, and I can prove that. So, um, not not being honest about their need for help or their use.” (CWS8)
	“It's just things - puzzle pieces just not don't connect. Sometimes you know also, I think too that they are a little bit more sneakier.” (CWS3)
Unmotivated, unwilling to change	“All of these people, they're bad mouthing, 'they're never going to get help. Once an addict, always an addict.'” (Provider8, referring to community attitudes)
SU/D Service Stigma
Harm reduction attitudes	“Some of the places that we go, people are all about it they want us to set up tables, they want us to meet [sic] with the community and everything, and then the other half carry around that stigma and you know, aren't too compassionate about addiction.” (Provider11)
MAR attitudes	“Courts are fine with suboxone, vivitrol. Methadone might be a little bit harder for our courts to wrap their heads around.” (CWS11)
	“She talked about the Suboxone program. And boy, I could really talk forever on that… But she was saying the biggest thing that helped her [sic] was going to jail because in the jail in [redacted] County, our jail doesn't allow Suboxone. And that helped her get clean. But then I hear these other jails like [redacted] County, they offer the Suboxone there.” (CWS19, referring to parent who used to be on suboxone)
Community Neglect	“So yeah, I do think there's a stigma… there is a need to like want to cover that up kind of, make [sic] it look like we don't have that issue here when we definitely do.” (CWS16)
	“I think that [redacted county] is a county that sweeps it under the rug…When it's within our family, we just hide it. It's not something that we actively seek to get help for.” (CWS18)
CWS Policies	“Not everybody can progress at the same pace, but there’s a timeline with [CWS] and unfortunately especially with substance use, relapse is part of the process. It can take a lot longer for them to even really maintain sobriety and stability.” (Provider22)
	“My thought would be that policy and procedure and law get on board with treatment and maybe not even get on board, but come together.” (CWS28, referring to suggestions for needed changes in CWS)
Intersecting Stigma	Intersecting stigma are other conditions that are also stigmatized, and in turn exacerbate potential stigmatization.
CWS stigma	“I think just like the stigma, I feel like people have really negative attitudes and beliefs around people involved with [CWS].” (Provider2)
Stigma Experiences	Lived realities or experiences of being stigmatized.
Structural/organizational stigma experiences	“I’ve heard them say that we’re trash… they just they have that judgment towards us before they even know who we are.” (Parent4, referring to CWS)
Public stigma experiences	“They’re like, just be honest with the kids. But then they’re still very judgmental…like if you’re judgmental now…they don’t think they are. But they are.” (Parent20, referring to judgment from family)
Self-stigma experiences	“I think there's a whole, you know, guilt and shame component that goes into saying that your substance use is negatively affecting your kiddos.” (Provider18).
Stigma Practices	Actions, beliefs, attitudes that actively stigmatize others.
Stigmatizing language	“I do think that there is a pretty good understanding of no one wants to grow up to be a drug addict. No one wants to grow up and get their kids taken right.” (CWS15)
	“We're not here for [CWS], we're here for the people…for the recovering addict.” (Provider14)
Stigma Outcomes	Consequences of stigmatization that exacerbate stigma and lead to negative outcomes for the population stigmatized.
Housing/employment access	“It's very difficult for them to get jobs or be in any type of like role of sorts. Like it's very difficult. Like a lot of my clients have to work at gas stations or things like that because they their employers won't - even if it was a while ago - they won't hire them.” (Provider19)
SU/D service availability	“The further you get out from you know, the more populated areas in [redacted county], the greater the stigma becomes and the, you know, more difficult it is to access those resources.” (Provider18)
	“I personally would like to have like more like MAT options at [treatment center], but it's not really in our scope.” (Provider10)
	“We're not even allowed to have Narcan in any of our county offices… it's a liability is what the state has directed to us. And so, you know, just things like that. Just I think they put a stigma on stuff.” (CWS2, referring to lack of naloxone in CWS offices)
CWS practices	“I would say the court would be the harshest when it comes to the parents who are using fentanyl just because of how dangerous it can be. They are usually quicker to remove a child if the parents are testing positive for fentanyl on a consistent basis just for the safety of the child, especially if it's an infant. Most of my cases are drug exposed infants, so a lot of those children end up being removed if the parent continues to test positive after the pregnancy. So, I would say it's probably harsher.” (CWS29)
Positive Outcomes	Responses to stigma that seek to combat and reduce stigma.
Stigma reduction efforts	“[Provider redacted] does a really good job, I think of marketing and like talking about mental health awareness and substance use, through like social media or just the news in general radio. So, there's certain things that are geared towards it.” (Provider27)
	“We are trying to change the stigma just with the language that we use. So, I think as a whole [redacted county] is, you know, taking a step in the right direction. But I do think there's so much more to do at the same time.” (Provider15)
	“We [community] have like a substance use council and stuff that puts on events and stuff like that. So, I do think that we're working to change that.” (CWS16)
CWS responses (FRC)	“Initially when we started our problem-solving court, people had a hard time with the fact that it was non adversarial and that we, I mean we really believe the way you replace bad behavior is with positive reinforcement.” (Provider19)
	“[FRC] does help the parents get through it better because I thought they thought they had more support at times.” (CWS4)

3. Results

Table 1 displays participant characteristics and Table 2 displays codes, themes, and example quotes. Fig. 1 displays an illustration of the results according to the HSDF. Themes related to stigma (all codes) were present in 96.8 % (n = 30) of CWS provider, 75.0 % (n = 21) of parent, and 96.4 % (n = 27) of service provider interviews.

3.1. Drivers/facilitators

Drivers/facilitators were specific to SU/D and included factors at multiple levels, such as beliefs/attitudes about SU/D and addiction, stereotypes of individuals with SU/D, and organizational and public practices and policies.

3.1.1. Beliefs about SU/D and addiction

Views of SU/D or addiction as a controllable condition was a predominant driver of stigma at the individual, community, and structural level. Participants pointed out community views and common narratives of SU/D: “[Communities] don't look at the disease concept, they just look at it as well, it was a choice that you made, and you did it. But they don't see the disease part of the addiction part of it” (Provider12). Many perceived these views as a lack of understanding of the disease model of addiction; even CWS’ acknowledged these perspectives of SU/D within their own system: “[CWS] look[s] at addiction as ‘Just stop doing drugs. Get your kid back.’…I think there is a lot of stigma there” (CWS6). Table 2 displays additional examples of individuals’ lack of understanding leading to negative judgment.

3.1.2. Stereotypes of ParWUS

Other drivers and facilitators were related to stereotypes of individuals who use substances and ParWUS substances in particular; common stereotypes included perceptions of ParWUS as dishonest and manipulative; unmotivated and unwilling to change; and not caring for their children.

ParWUS were commonly perceived by communities as not caring for their children or “choosing drugs over their children” (CWS15). One parent felt others viewed their addiction “as a lack of care or love for [my] kids” (Parent22). Others described beliefs that parents do not deserve to raise their children: “Everyone automatically assumes that if you are struggling with substance use that you should have your kids taken forever” (Provider8).

ParWUS were stereotyped as dishonest and manipulative. Both CWS personnel and service providers described parents as untrustworthy and “dishonest about their use” (CWS8), explaining: “everyone knows parents are going to go in and totally deny or make themselves look better than what they are” (CWS3). In fact, CWS personnel and SU/D service providers described working together to address parent dishonesty: “If systems aren’t communicating well enough, then that manipulation can happen in that gap.” (Provider16)

ParWUS were also perceived as unmotivated and unwilling to change. Both CWS personnel and providers perceived individuals’ motivation as a driving factor in their success. For example, one CWS personnel described:

The biggest challenge for parents is where they are in that state of change…if they are able to acknowledge where they're at and willing to acknowledge that they need help…It's the biggest determining factor regardless of the homelessness, regardless of the unemployment. (CWS26)

Even further, others believed that continued use must be a result of not wanting to change: “they have to hit the rock bottom in order for them to want to make some changes. But I mean, having your kids removed we would think that that would be the rock bottom, [but] it might not be” (CWS6).

3.1.3. SU/D service stigma

Evidence-based practices to treat addiction, including naloxone and other harm reduction strategies, and medication assisted recovery (MAR), were controversial. While some participants were accepting of harm reduction and MAR, others expressed negative opinions, especially regarding suboxone and methadone (see Table 2). Many participants noted their community’s hesitancy towards harm reduction:

It's [a] mixed bag. Some people get it…but everything good is always met with just like a little bit of distension, like when we got a vending machine for naloxone at the hospital…there were a few that [were] like, ‘why can't diabetics get free insulin? You know, you're giving out free Narcan to drug addicts, but you won't give insulin.’ (Provider14)

One provider described how she faced resistance in expanding harm reduction services in her community:

We tried at first to go over what we thought was low hanging fruit and that was just pushing Narcan out to the communities having the naloxone boxes, having it available in workplaces and that sort of thing and the push back we have received. I felt at one point in time was almost gonna cost me my job. Some of our political leaders really got upset and were not very nice about it…a lot of the people in our community here locally who are in decision-making roles still struggle with it. (Provider16)

Participants also described similar attitudes towards MAR. One provider described the opinions of MAR within the local recovery community:

My mind is really open to methadone, buprenorphine, naltrexone and still saying that Mom or Dad is substance free – that's not the case in the 12-step community here…let's say Mom's getting sublocade now. If that is known, there will be people who will tell her that she's not really clean…It's like there's a lot of stigma surrounding medication assistant therapy, there's a lot of surrounding moms who have experience with substance use and [CWS] they're frowned upon. (Provider5)

Some participants themselves had concerns about MAR. For example, one CWS personnel expressed: “This whole suboxone thing…it’s just blown up…You end up taking this suboxone forever.…It’s a drug replacing another drug, you know, the way I look at it” (CWS19). Another community provider similarly shared her opinions of methadone: “We have had way less results with methadone….we try to steer people away. I mean, I'm just gonna say, I detest methadone” (Provider19).

3.1.4. Community neglect

In smaller counties, participants described how their communities ignore the presence and impact of SU/D or take a perspective of “not in my community” (Provider27), and how this in turn perpetuates stigma. For example, one CWS personnel shared:

They try to act like it's not there. We have had some like recovering addicts that have tried to open a rehab facility in [county redacted] and the higher ups have said ‘Ohm, we don't have that problem here. Why would we bring people with substance use to our county?’ (CWS9)

Other participants also talked about how individuals in their community “sweep it under the rug” (CWS18, Provider8) in reference to acknowledgement of SU/D within the community and even within their family because it’s considered “so taboo to talk about” (Provider8).

3.1.5. CWS policies

Both service providers and CWS personnel described how CWS policies to address SU/D are lacking. This in turn can set parents up for failure, perpetuating stigma:

We don't necessarily have policy on substance use. We have policy on how to implement drug screens and stuff of that nature. I think if we had a policy on how to actually work with substance use and addictive parents, it would go a lot better. (CWS20)

Moreover, existing CWS policies often did not align with substance use treatment requirements. Many described the challenges of trying to meet CWS requirements for case timelines which were often shorter than CWS expectations for completing SU/D services, as one CWS personnel described: “legal timelines don’t match up with a person’s substance use” (CWS13).

3.2. Intersecting stigma: CWS involvement

The primary intersecting stigma related to negative views of CWS involvement, particularly as perceiving individuals in CWS as bad parents and not deserving of their children. As one provider shared, “people have really negative attitudes and beliefs around people involved with [CWS]” (Provider2). Another community provider similarly stated: “You have a CWS case and you’re the worst mom ever. It’s that stigma that goes along with that” (Provider9).

3.3. Stigma experiences

3.3.1. Organizational/system stigma experiences

Parents shared experiences of being judged and treated differently by the healthcare system and CWS. One parent shared: “In the hospital, when you tell them you’re an addict, even if you’re not a mom, they treat you different” (Parent27). Parents expressed similarly being judged by CWS: “Sometimes they hold a judgmental thinking process towards people like us. And I’ve even heard them say that we’re trash…they just have that judgment towards us before they even know who we are” (Parent4). Another parent described being reprimanded by CWS:

‘You keep making the same mistake again. You're never gonna learn. You're only doing this because you don't want your son’…they beat me up over that…they pretty much called me a bad mom and said, you know, ‘you're choosing yourself over your son.’ (Parent24)

This stigmatization made engaging in services and connecting with providers challenging, as one parent described: “It was really hard to talk to them…Their first initial reaction will always be aggressiveness or, you know, they would be very mean” (Parent14).

3.3.2. Public stigma experiences

Judgment, rejection, discrimination, and isolation from family and loved ones was common; many parents described losing social support and feeling isolated: “My brother, he isn’t an addict…so, there’s not, I wouldn’t say a stigma…it’s more like unsure, keeping their distance” (Parent23). Another parent similarly described: “I felt like I lost all their support completely…I wasn’t any good to them is how it felt” (Parent18). Parents also described stigmatization from the larger community:

The community as a whole still holds that stigma. If you didn’t know me, you’d have no idea I was ever a heroin user, right? But there is a stigma to it. Shame on me. You’re a scam. You’re a piece of shit. Like all those things come out from people. I see how they react to people that are currently in active addiction walking down the street. I hear those comments and see their reaction and stuff and it’s like it’s very frustrating” (Parent4).

3.4. Stigma practices: stigmatizing language

Stigma practices are stigmatizing beliefs, attitudes, and actions. While stereotypes – described as a driver – can also be practices, we use a narrow definition of stigma practices as stigmatizing behavior demonstrated by participants in the form of stigmatizing language used during interviews. For example, the term “addict” was mentioned at least once in 33 % (n = 29) of interviews; “dirty” in reference to drug screens was used in 17 % of the interviews; and “clean” in reference to a state of abstinence or drug screening was used in 53 % of the interviews. Some instances of stigmatizing language were used to demonstrate or mimic language used by others, for example, one individual expressing community views: “they’re viewed [sic] like just another addict in town” (CWS17). Other uses of language demonstrated how such language was part of their typical vocabulary: “that is the most frustrating piece there is, you know, arguing about dirty drug screens” (CWS19).

3.5. Stigma outcomes

In addition to the direct outcomes of stigma experienced by parents, such as feeling shame and isolation as alluded to in stigma experiences, there were also other impacts of stigma on organizations and systems, that in turn, further negatively impacted parents and even perpetuated stigma.

3.5.1. Housing / employment access

Participants described significant barriers to housing and employment due to policies related to SU/D history. One provider explained: “Nobody wants to give them a job. Nobody wants to give them housing. People don't want to give them transportation” (Provider14). This also resulted in fear of others learning of their SU/D history: “Most people don't want to admit if they're in housing that they have a drug issue because they're afraid they're going to lose their housing” (Provider17). Similar sentiments were experienced with respect to employment, as one provider described ParWUS being “very cautious or reserved about telling their employer that they have a case with CWS for substance use and [are] in treatment out of fear that they are going to be looked at in a different way with that employer” (Provider25).

3.5.2. SU/D service availability

Lack of evidence-based services, especially MAR, was a consequence of negative attitudes. For example, one service provider working at a large treatment center offering residential and outpatient services described their programs as “completely abstinence based” and explained that their organization does not offer MAR because “there’s a lot of people who still have, like, very negative opinions of it” (Provider23). Another provider described strict policies within their organization which limited ParWUS’ ability to get MAR, explaining “we don’t typically start clients on those medications” and described how parents that receive MAR elsewhere have additional requirements – on top of CWS court-ordered requirements – which in turn “leaves the clients in a place where they’re really overextended” (Provider18). Table 2 provides additional quotes.

3.5.3. CWS practices

The lack of appropriate CWS policies addressing SU/D led to instances of differential treatment of cases involving ParWUS. There was a sentiment that CWS courts were more cautious and stringent with ParWUS in spite of CWS’ primary focus on child safety:

We really try not to mess around with substance use so we tend to lean more towards just removing the child from the environment, that type of environment altogether much quicker than we would with other types of abuse and neglect. (CWS22)

Some perceived CWS as being more punitive towards ParWUS. This was often felt with respect to drug testing: “If you relapse, if you have a [positive] screen. It sets you back in your reunification process and it's really discouraging to parents when that happen[s]” (CWS1).

3.5.4. Positive outcomes

Despite many instances of stigma, there were also many efforts to combat stigma and support ParWUS. Many participants were aware of persisting stigma and its impacts, and many described both individual and organized efforts to combat stigma within their own families, communities, and workplaces. As one peer recovery coach modeled: “In my office we are any path to recovery, we accept them all. We love them all. If you like it and it works for you, we are good with that” (Provider14). Table 2 displays examples of efforts to reduce stigma in the community and workplace.

Within CWS, some counties have established family recovery courts (FRC) to address SU/D. Providers and CWS involved in FRCs described the positive impacts and additional supports that FRCs provide for ParWUS. One parent described the positive experience of FRC: “Once I realized they were there to help me and not against me, it made a world of difference” (Parent 11).

4. Discussion

The current study adds to the literature on SU/D stigma by exploring the unique intersection of SU/D and CWS involvement and conceptualizing drivers, experiences, and consequences of stigma on individuals and the larger environment using the HSDF. Drivers and facilitators of stigma included a lack of understanding of SU/D; negative stereotypes of people who use substances and ParWUS (dishonest, manipulative, lacking motivation); the community’s neglect of addressing SU/D; and negative attitudes towards SU/D services, consistent with previous research (Cazalis et al., 2023). This stigma manifested at multiple levels, from family/friends, to CWS and the healthcare system, to the larger community. Instances of stigmatizing language used in interviews also illustrates the pervasiveness of stigma practices. As a result, ParWUS struggled to get basic needs met due to community and organizational policy and practices (e.g., housing/employment); were unable to access effective SU/D services; and felt punished by CWS.

Conceptualizing stigma according to the HSDF illuminates (1) the complex interplay and impacts of stigma across multiple socioecological levels and (2) the importance of considering multiple sources of stigma that can intersect to impact stigma experiences and practices. First, findings illustrate how multiple socioecological levels both drive and are impacted by stigma related to SU/D. For example, negative attitudes towards MAR in the community – which were even perpetuated within the smaller recovery community – impacted organizations’ provision of these services (which likely further drives stigma by not offering such services), parents’ ability to access such services, and organizational attitudes towards use of such services, as evidenced by CWS personnel’s negative attitudes towards certain MAR. Second, results also demonstrate the compounding effects of intersecting stigma – specifically stigma of CWS involvement – that manifested at multiple socioecological levels from community attitudes about parents in CWS to the healthcare system. Such findings beg the need for additional research to further understand CWS-related stigma (Bekaert et al., 2021, Dir et al., 2025). Moreover, findings for the intersection of stigma related to SU/D and CWS informs the need for additional research on SU/D stigma to consider other common intersecting stigmas that people who use substances may experience, such as the interplay of stigma related to criminal justice involvement and other social classes (Moore et al., 2024).

Taken together, findings underscore the need for SU/D stigma reduction efforts to address multiple socioecological levels and consider various sources of stigma that intersect. Awareness and acknowledgement of the stigma that ParWUS in CWS experience is critical given the added vulnerability due to stress of CWS involvement that ParWUS experience and the potential negative impacts of both SU/D and stigma on children/families. Stigma reduction that involves a combination of training/education regarding SU/D and providing a voice to or interacting with those with lived experince has been shown to reduce negative attitudes related to SU/D (Krendl and Perry, 2023, McGinty et al., 2018). Such stigma reduction efforts have been disseiminated in the form of media campaigns to target stigma at the community level (Krendl and Perry, 2023, McGinty et al., 2018) and have also been adapted for various healthcare settings (Khazaee-Pool et al., 2024). “Intervention stigma” (Madden et al., 2021), or negative attitudes towards MAR and harm reduction (Klein, 2020, López-Ramírez et al., 2023, Madden et al., 2021, Rudski, 2016), can also be addressed. For example, overdose education and naloxone distribution programs at the community and organization levels (OEND), academic detailing in healthcare settings, and dissemination and implementation efforts to expand access to such services could help to promote understanding of the effectiveness of such medications and increase practice uptake (Winhusen et al., 2020).

While much of the study findings parallel research on SU/D stigma more generally (Krendl and Perry, 2023), the study’s focus on ParWUS highlights needed efforts within CWS to address stigma, especially given the prevalence of SU/D among parents in CWS. CWS frontline personnel play a critical role in ensuring families stay connected to services and meet court requirements, and addressing stigma through additional training/education specific to SU/D and stigma reduction programs as described above could improve relationships between CWS and ParWUS and facilitate service engagement (Dir et al., 2025). Moreover, while CWS expertise and mission lies in child safety, additional education in the courts and consideration of how CWS policies (e.g., case timelines, decisions regarding home removals, case requirements) may differentially impact ParWUS is warranted.

4.1. Limitations

The study is not without limitations. Data is from one Midwest state and may not be generalizable to other regions. Second, qualitative data from parents are limited by those who were willing to participate; those who are the most stigmatized may not engage in research due to concern of judgment or negative impacts, thus, many perspectives and experiences may not be represented here. The HSDF was also adapted post hoc to completing interviews and some constructs are not represented. Stigma is complex and multi-faceted, and multiple frameworks exist (e.g., Cheetham et al., 2022); results are limited to use of the HSDF given the fit of results with the framework. Lastly, due to sample size, differences in participant experiences across demographics (race, ethnicity), case status (open vs. closed case), or other potential characteristics were not explored.

5. Conclusion

Results provide a novel perspective on stigma experienced by ParWUS in CWS and highlight the multiple socioecological levels involved in perpetuating stigma. Findings inform future research and policy implications acknowledging the intersecting stigma experienced by this vulnerable group.

Ethics statement

All study activities were approved by Indiana University’s Institutional Review Board (IRB # 16674) on January 25, 2023. Study activities were deemed exempt, waiving written consent requirements. Participants were provided a study information sheet explaining the risks and benefits of the study before agreeing to participate.

CRediT authorship contribution statement

Brielle L. Batch: Writing – review & editing, Writing – original draft, Project administration, Formal analysis. Dir Allyson L: Writing – review & editing, Writing – original draft, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization. Aalsma Matthew C: Writing – review & editing.

Author disclosure

The authors have no conflicts of interest to disclose. This work was supported by the National Institute of Drug Abuse [NIDA; grant number: K23DA055210-01]. NIDA was not involved in the conceptualization, design, data collection, data analysis, or writing of this manuscript, and do not reflect the views of the organization.

Funding

This work was supported by the National Institute of Drug Abuse [NIDA; grant number: K23DA055210-01]. NIDA was not involved in the conceptualization, design, data collection, data analysis, or writing of this manuscript.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary material

Supplementary material

Data availability

Data from this study will not be available to protect the anonymity and confidentiality of sensitive material discussed by study participants.