Potential Emerging Risks Among Children Following Parental Opioid-Related Overdose Death

Abstract

This cohort study examines the human service encounters and mental health service use of children who experienced parental loss because of opioid-related overdoses in Allegheny County, Pennsylvania.

The incidence of unexpected deaths from opioid overdoses sharply increased in Allegheny County, Pennsylvania, in recent years. In 2017 alone, the county’s opioid-related overdose rate was 51.5 per 100 000, more than triple the US rate (14.9 per 100 000). This represented more than 90% of all unintentional overdoses.

The opioid epidemic is also affecting families and, most importantly, children. People who died of an overdose were most frequently between age 25 to 54 years and in their child-rearing years. Substance use in the household is considered an adverse childhood experience and is associated with health risks and disease in adulthood.¹ A recent longitudinal study found that bereavement by sudden parental death was associated with an increased incidence of depression, primarily during the first 2 years, along with posttraumatic stress disorder and functional impairment.² Yet, little is known about the number of children who experienced these losses.

The goal of this study was to determine the number of children who experienced unexpected parental loss because of opioid-related overdoses in Allegheny County. It also sought to understand their human service encounters and mental health services use subsequent to parental loss.

Methods

Using integrated public system data that existed within the county’s data warehouse, we identified a cohort of individuals who had died of an unintentional drug overdose between July 2002 and December 2017 who were also listed as a parent on a birth certificate between January 1999 and December 2017. The result was a cohort of children and adolescents born in Allegheny County who were 18 years or younger during this period and who may have been affected by an unexpected death of a parent.

We then summarized their involvement with human services and other public systems in the months and years following the parent’s death (when appropriate and age-eligible) and presented cumulative percentages (Table). This study was conducted by the department using information that already existed in the department as records of operations from the delivery of heath and human services. It was conducted for planning purposes and to improve the quality of services the department delivers to county residents and qualified as exempt research.

Table. Eligible Cohort Observed Over the 5-Year Period.

Characteristic	At time of parent's death	After parent’s death
		1 mo	3 mo	6 mo	1 y	2 y	5 y
Child welfare involvement
Cumulative count of bereaved children, No. (%)
Involved with child welfare	105 (10.6)	138 (14.0)	139 (14.1)	160 (16.2)	183 (18.5)	190 (19.2)	196 (19.8)
Involved in child welfare and placed out of home	33 (3.3)	48 (4.9)	53 (5.4)	60 (6.1)	72 (7.3)	79 (8.0)	84 (8..5)
Cumulative count of children who were age 0-17 y during observation periods, No.	989	989	989	989	989	989	989
Mental health services (Medicaid only)
Children who received ≥1 mental health services, No. (%)	71 (9.3)	84 (11.0)	110 (14.5)	132 (17.3)	149 (19.6)	169 (22.2)	189 (24.8)
Children who were Medicaid-enrolled during ≥1 of the observation periods, No.	761	761	761	761	761	761	761
Family court involvement for dependency reasons
Cumulative count of children in family court for dependency, No. (%)	71 (7.2)	87 (8.8)	91 (9.2)	96 (9.7)	104 (10.5)	108 (10.9)	112 (11.3)
Children age 0-17 y during observation periods, No.	989	989	989	989	989	989	989
Family court involvement for delinquency reasons
Cumulative count of children in family court for delinquency, No. (%)	13 (2.0)	13 (2.0)	15 (2.3)	17 (2.6)	20 (3.0)	22 (3.3)	24 (3.6)
Children age 10-17 y during observation periods, No.	665	665	665	665	665	665	665

Results

There were 664 individuals listed as parents on the birth certificates (392 [59%] were fathers) of 1008 children (989 [98%] were younger than 18 years): 252 (25%) were younger than 5 years, 373 (37%) were between age 5 to 9 years, 262 (26%) were age 10 to 14 years, and 131 (13%) were age 15 to 18 years. Within 3 months following the parent’s death, nearly 1 in 10 of the Medicaid-enrolled children had used mental health services (11.1%). Within 5 years, this had increased to nearly 1 in 4 children (24.8%) (Figure).

Figure. Mental Health and Human Services Encounters Following Parental Overdose Death.

At the time of the parent’s death, nearly 1 in 10 children was involved in child welfare (10.6%). Within 5 years, this had increased to nearly 1 in 5 children (19.8%). Within this time, 8.5% of the children had experienced out-of-home placement.

Dependency-related court involvement increased from 7.2% at the time of parent’s death to 11.3%. Delinquency-related court involvement remained relatively low throughout the 5-year period.

Discussion

Over a 16-year period, more than 1000 children lost a parent because of an unintentional drug overdose. These children experienced elevated risks for mental disorders, as observed by increased mental health service use in the years following parental death. This finding is consistent with a prior longitudinal study. Increased involvement in child welfare and out-of-home placement seems to reinforce our understanding of the potential for drug use interfering with child safety and parental care.

This study provides evidence of the challenges and emerging health risks experienced by children as a result of the opioid overdose epidemic. It is likely an underestimate given our methods, the aging of the cohort over time, and the variations in family composition. Public discourse regarding clinical approaches and policies to address the effect of unexpected loss among children is warranted, as it is an underrecognized dimension of the country’s opioid epidemic.