Creating a Path from Crisis to Care and Connection: Perspectives on Child Removal and Family Separation From Parental Substance Use

Abstract

Family separation due to parental substance use negatively impacts not only caregivers and children but also family networks, foster parents, and providers who support these families. This qualitative study examined the experiences of birth, kin and foster parents, and medical, behavioral, and community providers with child removal and custody loss. Twenty-six individuals participated in five focus groups where three themes emerged: 1) insufficient support for families at the time of removal exacerbates the trauma of custody transitions across all groups; 2) the lack of transparency in the child removal process fosters mutual mistrust; and 3) opportunities exist to enhance support for families facing the challenges of child removal. Holistic strategies that minimize trauma and address the needs of families, caregivers, and professionals who interact with the child welfare system are critical to enhance the well-being of families affected by parental substance use.

Background

The effects of unhealthy substance use and substance use disorder (SUD) extend beyond the individual, significantly impacting the entire family system, including infants, children, and adolescents. Between 2015 and 2019 in the United States, more than 21 million children annually, or 16% of all children, lived with a parent who misused substances, and more than 2 million children (approximately 2%) lived with a parent who had a substance use disorder (not including alcohol use disorder) (Ghertner, 2022). The rates of parental substance use among those actively engaged in caregiving vary by age of child and parental race but are similar across urban and rural locations (Ghertner, 2022). The presence of substance use among caregivers is linked to an increased risk of involvement with the child welfare system (Ghertner et al., 2018). Over the past two decades, parental drug and alcohol use has become a rising factor in child custody removals in the United States, increasing from 18.5% in 2000 to 39.0% in 2020 (Prevalence of Parental Alcohol or Drug Abuse as a Condition Associated with Removal | National Center on Substance Abuse and Child Welfare, n.d.). Further, for all reports to child protection services involving infants aged one and under, 13% were identified to have prenatal substance exposure (Durrance & Atkins, 2024) and 51.4% of custody removals for infants under one year old were attributed to parental substance use (National Center on Substance Abuse and Child Welfare, n.d.).

Studies have demonstrated that parental substance use poses its own set of potential risks to children, such as increased risk of unintentional ingestion, impaired caregiving, exposure to violence and chaotic home environments, and witnessing overdose (Clément et al., 2016; Gaither, 2023; Gaw et al., 2023; Mossaides, 2019). However, children placed out of parental care also face unique challenges, such as trauma from the removal itself, instability from multiple foster care placements, and high rates of abuse in foster care (Mitchell, 2018; Mitchell & Kuczynski, 2010). Research on the long-term outcomes for all children separated from their families and placed in foster care reveals an elevated risk of attachment disorders, adverse mental and physical health, adverse childhood experiences (ACEs), and a higher likelihood of developing substance use issues later in life compared with children who did not experience separation from caregivers (Engler et al., 2022; Koponen et al., 2022; Leve et al., 2012). Further, certain racial groups are overrepresented in foster care, with Black children experiencing rates up to 2.5 times higher than their proportion in the general population (Dettlaff et al., 2020; Roberts, 2022). Additionally, at every stage—from reporting and investigations to removal and placement—Black families are more likely to be involved with the child protection system compared to White families, raising concern among some scholars that the system functions more as one of regulation than protection (Dettlaff et al., 2020).

Child custody removal is also traumatic for birth parents, who often endure profound grief and a loss of identity as caregivers, in addition to the disruption of social and welfare benefits and stigma from child welfare, the courts, and social networks (Broadhurst & Mason, 2020; Burrow et al., 2024). Further, the degradation of parental mental health that can accompany custody loss may contribute to an increase in substance use, impacting their ability to regain custody of their child without intervening supports (Darlington et al., 2023; Wall-Wieler et al., 2017, 2018). Studies of mothers with SUD who have experienced custody loss reveal mixed perceptions of Child Protection Services (CPS), with some viewing CPS as judgmental and punitive, while others believing it to be a source of accountability (Falletta et al., 2018). The impact of child removal extends beyond the immediate family, influencing a broader support network, including both kin and non-relative foster parents. Studies of foster parents and kinship foster parents note negative mental health impacts due to social isolation, economic insecurity, and a lack of formal support (Cooley et al., 2017; Davis et al., 2020; Taylor et al., 2016).

Clinical and community supports, including medical and behavioral health providers, home visiting programs, and recovery supports for the parent and/or child, play a vital role during and after family separation, offering emotional, physical, and logistical support to both children and parents. However, the perspectives of these professionals surrounding custody loss have been less well described. One study of professionals involved in the child removal process reported insufficient health and emotional support for children, and identified resource gaps for alternate caregivers, highlighting the need for greater financial assistance, housing, and skill-building in areas like parenting and system navigation (Tye et al., 2022).

Substance use is the leading cause of removal of children under the age of one, accounting for over half of all removals in 2021 — a rate that has doubled over the past two decades. (Prevalence of Parental Alcohol or Drug Abuse as a Condition Associated with Removal | National Center on Substance Abuse and Child Welfare, n.d.) Synthesizing insights from diverse stakeholders involved in the custody removal process is therefore essential to designing effective, holistic strategies that minimize trauma and address the needs of families, caregivers, and professionals who interact with the child welfare system. This study utilizes qualitative methodology to understand the experiences of those directly involved in the process of child removal — birth parents, foster parents, clinicians, and community providers — to explore the experience of child removal in the context of parental substance use. Using semi-structured focus groups, this study examines ways to minimize the trauma of custody loss and enhance support to families during and after separation. By amplifying the voices of groups underrepresented in past research and triangulating findings across caregiver and professional role groups, we aim to deepen understanding of the impacts of family separation and inform policies and practices that reduce unnecessary removals, mitigate associated harms, and promote healthier family reunifications.

Methods

Study Design

From October to December 2023, we conducted five focus groups with key role groups affected by custody loss due to parental substance use. The study design and the development of the interview guide were informed by a community advisory board comprising clinicians, public health practitioners, and individuals with lived experiences related to child removal resulting from parental substance use disorder (including those who had experienced the removal of their own children, adults who had been removed as children, and current and former foster parents including kinship parents). Semi-structured focus groups were selected as they provided a practical way to engage multiple participants simultaneously, enabling the collection of diverse perspectives within a shared conversational setting. This format also fostered a supportive space where participants with similar lived experiences could openly discuss the complex and sensitive topic of family separation. Recognizing the potential challenges of discussing such deeply personal and potentially stigmatizing issues, we implemented several strategies to encourage open and honest dialogue. A highly trained, trauma-informed facilitator, with extensive experience in leading support groups, led the sessions, striving to create a space where participants felt respected and supported. Confidentiality was emphasized at the outset, and clear group guidelines were reviewed to establish a nonjudgemental and safe environment for sharing. These measures were designed to build trust and minimize barriers to honest communication, while acknowledging the inherent limitations of group dynamics.

The advisory board played a critical role in refining the key groups to include in our research. Based on their recommendation, we invited individuals who are actively engaged throughout the removal process, from the initial filing with child protection services to providing support during removal and reunification. The five groups included: 1) community providers, 2) medical and behavioral health providers, 3) foster parents, 4) kinship foster parents, and 5) birth parents who experienced a child removal due to parental substance use disorder. The perspectives from a sixth group, child protection system social workers, were identified as a critical voice, but we did not receive permission from the state agency to recruit from this group.

The initial interview guide was developed by integrating clinical insights and professional experiences from the study team. This guide was then iteratively refined through ongoing feedback from the advisory board, focusing specifically on the immediate events surrounding child removal. This focus was chosen to reflect the emotional salience of the advisory group’s reflections and their desire for improvements in this challenging period. To ensure relevance to the diverse groups involved, separate interview guides were created for each participant group. While the interview guides were tailored to each group’s experiences and roles, they were anchored by a shared set of core domains, including temporally examining the periods before, during, and after child removal; perceptions of available and missing supports; and the child’s experience from the perspective of the participant. For example, birth parents were asked about what supports they received or wished for, while providers were asked what supports they offered or observed as lacking. The advisory board’s diverse expertise, including insights from individuals with lived and professional experience of parental substance use and child removal, guided this process, ensuring that the questions addressed key concerns relevant to each group while maintaining a consistent focus on the broader research topic. The interview guide can be found in the Appendix. This study received approval from the MassGeneral Brigham Institutional Review Board.

Participants and Recruitment

Key partners were invited to participate in one of five focus groups, based on their affiliation: community providers, medical and behavioral health providers, foster parents, kinship foster parents, and birth parents. Participants self-identified as affiliated with one of these groups, residing or working in Massachusetts and had either direct experience or roles in supporting families affected by child removal related to substance use. Eligibility criteria included being English-speaking and having access to Zoom videoconferencing; parents were eligible regardless of their current child custody status.

Recruitment strategies were tailored to each group. Email outreach efforts targeted clinics that provide services to pregnant and parenting individuals with substance use disorders, recovery community centers, community outreach programs, and support networks for foster families. Clinical research coordinators facilitated participant recruitment by distributing flyers and directly contacting program staff. Once a potentially eligible participant expressed interest, the coordinators reviewed the eligibility criteria, obtained verbal consent, and emailed information for joining the scheduled focus group.

Data Collection and Analysis

Sessions were conducted by a cis-gender white woman on our team working as a clinical social worker and with expertise in focus group facilitation, experience supporting families affected by child custody loss due to parental substance use, and lived experience as a foster parent and with adoption. In her professional role, the interviewer had interacted with some members of the medical/behavioral and community professional groups in various capacities. These sessions took place over secure Zoom videoconferencing, were audio-recorded, transcribed verbatim by an external transcription service, and manually deidentified prior to analysis. Demographic data, including self-reported data on participant race/ethnicity, were collected through an electronic survey administered after the completion of each session. Participants received a $50 gift card as remuneration.

Thematic analysis was employed to identify patterns within the data. Four members of the research team independently reviewed and discussed all five transcripts to develop a comprehensive codebook comprising nodes and sub-nodes. This final codebook was then utilized by three independent reviewers to analyze all transcripts using NVivo 12 qualitative software. Each transcript was coded by at least two independent coders, who then engaged in discussions to reach consensus on their coding decisions. A third coder reviewed each transcript and facilitated this consensus process (Hemmler et al., 2022).

Although a common coding structure was applied across transcripts, the transcripts were initially reviewed by participant group to allow for within-group theme development and attention to role-specific nuances. The final codebook included broad nodes applicable across groups (e.g., “missed opportunity for support,” “impact on child,” “communication with DCF”) and sub-codes that captured variations in language or framing. Coders considered the participant’s role when applying the codes, and consensus discussions explicitly addressed how a theme might manifest differently by role group. Rather than assuming a uniform experience across groups, we aimed to identify both patterns and distinct role-based insights. This approach supported a more complete understanding of the custody removal experience from multiple stakeholder perspectives.

To ensure rigor and trustworthiness, we employed strategies such as investigator triangulation, with multiple coders independently reviewing and discussing data to reach consensus on themes. Biweekly team meetings provided a forum for critical discussions, addressing questions, identifying potential biases, and refining the analysis. Our multidisciplinary research team contributed diverse expertise, in both medical and community settings caring for families affected by SUD. While these perspectives enriched the study design and analysis, we engaged in reflexive discussions and incorporated feedback from a community advisory board to mitigate bias and ensure representation of diverse viewpoints. Key themes were identified by grouping related subthemes and summarizing illustrative quotes.

Results

Study Sample and Participant Characteristics

A total of 57 individuals expressed interest in the study. A total of 30 individuals met the eligibility criteria and provided consent to participate in the study. Of these, 26 individuals actively participated in one of the five listening sessions. The breakdown of participants by session is as follows: 9 community providers, 3 non-kinship foster parents, 3 birth parents, 5 kinship foster parents, and 6 medical and behavioral providers. All participants identified as female. Participant demographics are reported in Table 1. Additionally, participant-specific questions were asked to provide insights into their professional and lived experiences. Birth parents reported having an average of 2 children and experiencing 1.5 child removals (SD = 0.71). Kinship and foster parents had served as alternate caregivers for an average of 8 years (SD = 4.36), while providers reported an average of 9.35 years (SD = 7.84) working with families affected by substance use.

Table 1.

Participant Demographics.

	Participants (n = 26)
	N (mean)	% (SD)
Age	47.28	12.07
Gender
Male	0	0
Female	26	100%
Race
American Indian or Alaskan Native	0	0%
Asian	0	0%
Black or African-American	4	14.8%
Native Hawaiian or other Pacific Islander	0	0%
White	20	74.1%
Mixed Race	2	7.4%
Other	1	3.7%
Ethnicity
Hispanic or Latinx	6	23.1%
Not Hispanic or Latinx	20	76.9%
Marital Status
Married	11	42.3%
Not married	15	57.7%
Highest Education Level
High school or less	4	15.4%
Some college or more	22	84.6%
Role Group
Birth Parents	3	11.5%
Foster Parents	3	11.5%
Kinship Foster Parents	5	19.2%
Community Providers	9	34.6%
Medical/Behavioral Providers	6	23.1%

Qualitative Themes

Three key themes surrounding child removal and family separation emerged from our analysis: (1) insufficient support for families at the time of removal compounds the trauma of custody transitions across all groups; (2) the lack of transparency in the child removal process fosters mutual mistrust; and (3) participants identified opportunities to enhance support for families facing the challenges of child removal.

Theme 1: Insufficient support at the time of and following child removal compounds the trauma of custody transitions.

Participants described child removal as an intensely traumatic experience, not only for birthing parents and their children, but also for the broader community. Their stories revealed that a perceived lack of support from the child protection system (CPS) amplified the emotional distress of custody loss and subsequent placement of a child.

Birth parents recounted receiving minimal guidance or assistance from CPS workers, which left them to navigate both their addiction and the complex child welfare system largely on their own. One birth parent stressed the importance of CPS providing more comprehensive support and services, rather than simply removing children and leaving parents to cope in isolation:

“When I gave birth… I was in active addiction. When they took her from me, I never even got to see her … The [CPS] worker just came in and basically told me they were taking custody of the baby… all she did was give me an action plan. It’s this is what you need to do, and you’re on your own to figure it out. I found that really hard. There was just—there was no support from my [CPS] worker. I know that’s a traumatic experience, and it should straighten you out and make you wanna do the right thing, but it sent me for a whirlwind, and it made me—it made my addiction worse, because I was so traumatized from what happened. All I knew how to do was use at that point. That’s how I coped with my feelings… I just felt lost, and I felt like I was alone. It was just a really hard experience.”

(Participant 2, birth parent)

A community provider reflected on the challenges of feeling that CPS doesn’t provide enough support—whether through material resources or emotional care—to children who experience a transition in their primary caregiver:

“I think if [CPS] had more support to address these issues that—they’re making this happen, so how can we support these parents to help them get through this? How can we support the children to help them get through this? Because I feel like they just take ‘em and they dump ‘em. Fend for yourself. Figure it out. That part bugs me a lot.”

(Participant 8, community provider)

Foster and kinship parents caring for children of parents with substance use disorders also faced significant barriers in accessing supportive care, including stigma when seeking mental health services, limited guidance from CPS regarding their role and responsibilities, and insufficient resources following placement. One foster parent described her experience with post-placement stressors as being similar to postpartum depression, and noted how challenging it was to go through that period with minimal supports:

“I’ve never heard anybody else say it, but I say post-placement depression … I thought I would be a fantastic foster parent. How naive of me of not understanding how intense this is. I don’t know. Sometimes I joke, but not joke and say, if somebody had told me how bad this actually really was, I wouldn’t have done it. I wouldn’t have signed up. Now I can’t turn away from it. Some people can… It’s not talked about. There’s no support. Like [other participants] have said, it’s like it’s shamed if we want to talk to anybody… The social workers, I think, get two therapy visits a year or something through [CPS]. It’s like, why aren’t we mandated to talk to somebody?”

(Participant 22, foster parent)

Additionally, a foster parent felt punished for seeking mental health supports to navigate the psychological toll of fostering. When they were prescribed a medication for anxiety, they felt the need to hide the indication from their adoption worker who would not approve their home study until they spoke with the parent’s therapist:

“I went on medication because my anxiety was so high [but] my doctor put it in my chart that it was for headaches. She mainly did it because she didn’t want [CPS] to hold it against me. When I was adopting my daughter, we were finishing up our adoption home study, and the supervisor would not sign off on it until [they] spoke to my therapist and made sure that I was okay to adopt. I’m just trying to work with a professional to talk about how hard being a foster parent [is][…] What was holding up our home study and needed to be signed off on was the fact that I went to therapy. I was like, it’s so unfair.”

(Participant 17, foster parent)

Kinship parents had a unique perspective when caring for their grandchildren or a relative’s children, balancing their wishes for their child or loved one who was struggling with addiction, and that person’s need for support, with the immense demands of providing care for the child placed with them and feeling doubly responsible for both the parent and the child:

“I’d say if I had to give any advice, don’t give up. You have to just keep plugging. Don’t give up on your children, don’t give up on your grandkids, don’t give up on your situation because without you, then who? If not you, then who? If we look at other people that take people’s kids and don’t really care, and then there’s us that care, and really care. There’s a system that really doesn’t care about us either… There’s a system out here that’s broken, really broken.”

(Participant 19, kinship grandparent)

Theme 2: Inconsistencies and lack of transparency throughout the child removal and caregiver transition process created confusion and mistrust.

Interviewees from all groups highlighted an absence of standardization in the child removal and custody transition process, noting inconsistent practices, fragmented communication, and lack of transparency in the CPS decision-making process. These factors fueled frustration and mistrust, leading many to view CPS as a key contributor to these challenges.

Participant 8, a community provider, reflected on their experience working with families, expressing a need for “more consistency with who gets removed [and] who doesn’t get removed [as] there’s rarely consistency with things.” Another community partner, participant 12, emphasized the importance of clear communication so that “there’s time to prepare and [birth parents] had a complete understanding of what was expected.”

A behavioral provider underscored the importance of transparency and involving families—both parents and children (when developmentally appropriate)—in discussions about their cases to ensure they are fully informed and supported throughout the process:

“I think, as a former [CPS] worker, we gotta stop having conversations without the right people in the room. Unfortunately, removals do have to happen sometimes, but they can be done in a way that is not retraumatizing an already-traumatic situation, and bringing the patient in on those conversations, ‘cause a lot of times these conversations that are happening about the concerns are happening without the patient. How are they gonna work on the concerns, if they don’t know what they are? Then, all of a sudden, you have two [CPS] workers and a police cruiser showing up at your house, after 5:00 p.m. on a Friday, removing your children, and none of your supports are around for the whole weekend.”

(Participant 21, medical/behavioral provider)

A birth parent described how the goalposts around reunification kept shifting. Even when one requirement was met, a new one would often be introduced after the first was completed:

“I had no help. I was so determined, ‘cause she promised me. [CPS] was like oh, if you go to a place, I will give you your kids within three months…Then I got there, three months went by, and she’s like it’s not enough sober time. I’m like what?”

(Participant 10, birth parent)

Frequent CPS caseworker turnover was identified as another key factor contributing to inconsistent messaging and a perceived lack of transparency:

“Every time I got comfortable with the [CPS] worker, they would leave to go to another job, so I was getting another DCF worker. Consistency is very helpful. I think I’m on my fifth [CPS] worker in the last three years… It’s hard, ‘cause I get comfortable with one, and then all of a sudden, they’re like oh, I’m getting another job, or oh, I’m going on maternity leave. Consistency is super important.”

(Participant 2, birth parent)

Theme 3: Opportunities exist for enhancing systems of support by minimizing trauma for families facing child removal.

Participants underscored the critical need for a trauma-informed approach and comprehensive support systems to mitigate the difficulties associated with child removal due to parental substance use. They called for both tailored, practical interventions and aspirational improvements to CPS, medical, and treatment systems, and community resources, aiming to reduce trauma and offer meaningful support to affected families.

Kinship foster parents expressed a desire for structured training and resources, emphasizing the need for specific guidance on caring for children’s physical and mental health as well as practical tools and checklists to navigate medical and educational systems effectively:

“Not to give us homework like a handbook, but a training, some kind of tool, some kind of checklist, some kind of requirement laminated and give it to all parents. If you’re going to the doctor, this has to happen, when you’re enrolling in school, this has to happen, for [Early Intervention], this has to happen…”

(Participant 5, kinship foster parent)

Some participants envisioned more comprehensive reforms to better support families affected by substance use disorders facing child removal, including adopting models from other countries, such as assigning dedicated guardians to represent children’s interests:

“If the role of guardian ad litem was more robust here, similar—I keep talking about the UK system, but I worked it for 11 years, and I feel like it’s such a better child welfare system than here. We have something called [Children and Family Court Advisory and Support Service]. It’s a court-appointed guardian to each child in care. They represent the child, but not as the lawyer, like literally the child’s wishes and views […] but I feel like it’s like a system overall, like overhaul that needs to happen—like a big one.”

(Participant 20, foster parent)

One clinician called for exploring creative alternatives to removal that leverage natural supports and role modeling to aid parents in their recovery:

“In our experience, a lot of times physical removal doesn’t have to happen, maybe legal, but being creative and thinking outside the box, and really utilizing the natural supports that the patient has. I love the idea of having a foster mom for the moms, because…it’s hard to know how to parent, when you were never parented, and you also reflect a lot on how you were parented when you become a parent. We all learn—we all know that learning happens best when it’s role modeled. This is a perfect time to put somebody in place that can really be this mom’s mom. That way, that mom can be the mother her child needs.”

(Participant 21, medical/behavioral provider)

Ultimately, participants highlighted the need to shift societal attitudes toward substance use disorder by combating stigma and promoting its understanding as a medical issue rather than a moral failing, addressing an underlying factor that contributes to many family separations involving parental addiction:

“It’s no different than if you had some other medical disease, like just taking Tylenol. You’re in pain, you take Tylenol. I’m like you’re taking the methadone to treat your disease. I just so badly wish that people would understand that.”

(Participant 22, foster parent)

Discussion

Family separation due to substance use has far-reaching consequences that extend beyond the parent-child dyad, affecting those within and outside the child protection system. Our study included the perspectives of a diverse range of individuals involved in or affected by the child removal process and highlighted family separation and custody loss as a profoundly traumatic experience, and understanding the experiences of each key group provided a more comprehensive perspective on the overall process. Participants described that the challenging period following removal was compounded by a perceived lack of transparency and support from the child protection system for birth parents, their children, and foster parents. Participants expressed a range of perspectives, including a need for more structured training and resources to address acute needs when removals occur, alternatives to removal that leverage natural supports and advocates to aid parents in their recovery, and broader changes to shift societal attitudes toward substance use disorder to offer meaningful support to affected families.

Birth parents described feeling abandoned to navigate the complexities of the system alone after their child was removed, reflecting findings from prior research that has similarly highlighted a lack of formal and social support for birth parents post-removal (Burrow et al., 2024; Falletta et al., 2018; Kenny & Barrington, 2018). Kinship and foster parents also faced substantial challenges following a child’s placement, feeling under-resourced and isolated in their caregiving roles, particularly when it came to interacting with the child protection system (Letiecq et al., 2008). These findings underscore a systemic gap in support for both birth parents and alternate caregivers, suggesting a need for consistent, accessible resources to help these groups through the transition and ongoing care process in a way that minimizes trauma. One approach that is increasingly used to guide complex and high risk medical or surgical care is the use of timeouts and pre-procedure checklists and may offer an opportunity to guide caregivers and professionals through the socially high-risk removal processes to help reduce harm (Berry et al., 2018; Haynes et al., 2009).

Policymakers and practitioners are increasingly implementing strategies and practices to reduce unnecessary family separations. Recent policy changes across Massachusetts, for example, have modified mandated reporting requirements at the time of delivery for birthing parents who received medication for opioid use during pregnancy, reflecting a shift toward a more recovery-centered approach (Mass General Brigham, 2024). Additionally, cross-system collaboration, including interdisciplinary meetings that bring parents, clinical, community, and child protection system teams together, are being implemented to facilitate parental agency when interacting with CPS, Emerging research increasingly supports family-centered approaches, emphasizing that keeping substance-affected parents and their infants together during treatment promotes not only parental recovery but also the development of positive parent-child interactions (Renk et al., 2016; Usher et al., 2015). Literature suggests that when systems prioritize separation over attachment and care, the long-term emotional and psychological consequences for both parents and children can be severe (Raz & Sankaran, 2019; Sankaran et al., 2019). A shift toward recovery-centered practices that honor the parent-child bond and integrate trauma-informed care may reduce the harm caused by current child protection systems, which often exacerbate the trauma they are designed to mitigate (Merritt, 2020; Roberts, 2022).

Participants described CPS as heavily involved at the time of removal but largely absent in the periods before and after, revealing a focus on crisis management rather than sustained support—a shortfall that adds to caregivers’ stress and feelings of abandonment. This lack of support has significant consequences for caregivers’ well-being. Research has shown that child removal can contribute to negative mental health outcomes, including increased rates of post-traumatic stress disorder among birth parents involved in child protection processes (Suomi et al., 2021). Additionally, custody loss has been identified as a driver of substance use relapse, with some parents turning to substances as a coping mechanism to manage the emotional trauma of removal (Adams et al., 2021). In a longitudinal cohort in Canada, mothers who have had a child pass away reported better mental health outcomes two years post-loss compared to those who have lost custody of a child (Wall-Wieler et al., 2018). Similarly, alternate caregivers, particularly grandparent caregivers, often experience isolation from support networks and face economic insecurity due to the sudden caregiving role, contributing to worse mental health outcomes (Davis et al., 2020; Taylor et al., 2016; Tye et al., 2022). Participants pointed out the contradiction between CPS’s role in ensuring immediate child safety and its lack of involvement in fostering successful transitions, which can ultimately undermine the stability and well-being of the child. This gap between CPS’s intended goals and actual practices suggests a need for more trauma-informed, consistent support mechanisms that address both immediate and long-term needs for families.

Participants described navigating the child protection system as highly challenging due to inconsistent practices, fragmented communication, and a lack of transparency—all of which contributed to a perceived lack of support. For example, participants described unclear criteria for removal and reunification, inconsistent communication about placement processes, and opaque decision-making practices by CPS. These challenges were encountered throughout the entire continuum of interacting with the child protection system, from criteria for removal and the removal process itself, to placement of the child with an alternate caregiver and criteria for reunification. This systemic lack of transparency has been noted in prior literature, where birth parents and foster caregivers often perceive CPS practices as harmful, intrusive, and misaligned with their stated goals (Burrow et al., 2024; Cooley et al., 2017; Falletta et al., 2018). Finally, while participants focused on inconsistencies and mistrust of the child protection system, these challenges can have a trickle-down effect for birth parents, ultimately impacting their relationship with providers in medical and community agencies who are tasked with helping families meet the needs identified by child welfare teams (Schiff et al., 2022).

Despite feeling disillusioned by current practices in the child protection system, participants offered many recommendations for improvement, calling for a trauma-informed approach that better supports those impacted by child removal. When filing a report with CPS or during the acute removal, applying the principles of trauma informed care may include honoring the physiologic response of a parent who likely will be in a heightened “fight or flight” state. Additionally, prioritizing transparency, autonomy, and participation in the process—whenever possible—can include actions such as offering to call in a report to CPS together with the birth parent or participating in the selection of alternate caregivers if a removal is necessary. Highlighting a parent’s strengths, even in a time of child removal, can help mitigate the effects of the traumatic experience of separation (Schiff et al., 2024). As highlighted by a participant, the Children and Family Court Advisory and Support Service in England offers an advocate for children that could be more widely adopted in the United States (Cafcass Advises the Family Courts about the Welfare of Children and What Is in Their Best Interests | Cafcass). For older children, qualitative research with foster-care involved youth highlighted that involving their input in placement decisions can promote choice and agency and mitigate feelings of powerlessness over an inherently traumatic event (Saarnik et al., 2023). Another promising intervention, called the Sobriety Treatment and Recovery Teams (START), provides intensive case management and coordination across agencies and providers, recovery coaching, and linkage to substance use treatment services for families involved in child welfare and has been shown to increase reunification rates and reduce caregiver stress (Hall et al., 2021).

Across groups, there was a shared view—and an underlying expectation—that the Child Protection System should go beyond offering resources and referrals for substance use treatment and mental health services for parents, and also take responsibility for addressing broader structural determinants of health, such as unstable housing, poverty, and limited access to healthcare, which significantly influence custody decisions. While state child protection agencies are tasked with ensuring child safety, they are neither designed nor funded to address these wider, systemic public health issues. Empowering public health agencies to expand access to services families need to thrive, including home visiting programs, parenting programs, childcare, respite care, and material resources, rather than relying on surveillance is necessary to meet families’ needs and allow child protection agencies to focus on addressing acute safety concerns.

Limitations

There are several important limitations to our study. First, we hoped to conduct focus groups with child protection case workers who are on the front line when family separation takes place but unfortunately did not receive approval to recruit this key group. Future research should prioritize eliciting the perspectives of staff at child protection agencies. Additionally, limitations of focus groups include differential responses by participants within groups. While we believe participants were generally open and honest in sharing their experiences, participant dynamics within group discussions may still lead participants to self-censor, particularly when discussing sensitive topics such as child removal and substance use (Barbour, 2007; Krueger, 2014). Future studies might consider supplementing focus groups with individual interviews to provide additional opportunities for participants to share their perspectives in a more private setting, which could be especially beneficial for those who may feel reluctant to speak in a group context. The small numbers of individuals in each group, particularly birth and foster parents, also limits the generalizability of the themes. Furthermore, the racial composition of our sample—particularly among birth parents—may not fully capture the experiences of racially diverse families, who are disproportionately impacted by punitive child welfare policies (Dettlaff et al., 2020). Next, our findings may also be specific to the unique child protection system reporting approaches in Massachusetts. Finally, while we asked parents and caregivers about the perspectives of their children, we were unable to elicit the experiences of children directly.

Conclusions

Our findings underscore the profound and far-reaching impacts of child removal on the parent-child relationship, and its ripple effects extending to foster parents, kinship parents, and medical, behavioral health, and community providers. Family separation related to parental substance use often occurs abruptly during periods of crisis, leaving support systems struggling to mitigate the resulting harm. The absence of adequate support during this traumatic period not only intensifies the emotional and psychological toll on families but also disrupts the broader network of individuals and systems working to support them, ultimately undermining the family’s ability to recover and thrive. The child protection system operates under significant pressure to serve as both a safety net and a responder to acute child safety concerns. Building deeper public health systems to support families would allow CPS to better focus on addressing children experiencing abuse and neglect. Yet, CPS and its collaborating agencies must also acknowledge their role in exacerbating trauma during removals and take responsibility for their impact. Finally, while the fields of child protection and mental health already possess tools to address trauma, our findings emphasize the urgent need for their effective implementation and expanded access. Until systemic reforms are fully realized, bolstering trauma treatment remains essential to support healing and resilience among affected children, families, and communities.

Data availability:

Semi-structured qualitative focus group guides are included in an appendix and the final codebook with definitions is available by request. Deidentified transcripts are not available for dissemination.