Caring for Families with Young Children Affected by Substance Use Disorder: Needed Changes

The rise in substance use disorders (SUD), and concurrent rise in opioid use and polysubstance use disorders among pregnant and parenting women, places a significant burden on child health systems: medical, behavioral, and home-visiting.¹ Opioid use, specifically, has quadrupled over the last decade and over 30,000 newborns each year are diagnosed with neonatal opioid withdrawal syndrome, roughly 6 of every 1000 live births.^{2, 3} As pediatricians and clinician-scientists serving families affected by SUD, our clinical and research experience suggests significant limitations to the present clinic- and community-based services for this population, especially during infancy and the first five years after the birth of a child.^4–9 The separation of pediatric, maternal, and SUD care likely contributes to the structural barriers that interfere with optimal support for families affected by SUD.

We see a need for better collaboration and interdisciplinary training across a range of programs to meet the unique needs of these families and to support the long term development of affected children.^10–12 There is additional need for improved support of clinical and community providers that often take on stressors experienced by their patients and clients, especially when they face barriers to meeting the needs of these families.^{13, 14} These systems-level shortcomings have become increasingly apparent with the additional stress of the COVID-19 pandemic exposing the unique vulnerabilities of this population.^15–17

The goal of this commentary is to suggest approaches to improve service delivery and work environments that will result in better care for SUD-affected families. We identified three areas to better meet the needs of parents, their children, and providers: 1) clinical-community care coordination, 2) a shift in focus toward the parent-child relationship, and 3) trauma-informed systems for families and providers.

Care Coordination – Moving beyond the clinic walls

One consistent message we hear from postpartum women in recovery is ‘I am overwhelmed by appointments and responsibilities.’ In addition to caring for their baby, parents of newborns may be asked to attend multiple pediatric visits, sign up for supplemental food and nutrition programs, schedule visiting nurse appointments, comply with evaluations from child welfare agencies, obtain medication for SUD, and attend therapy or recovery meetings.^18–20 While mothers may need a variety of services, more services do not always equal more effective care. In the worst cases, some services intended to support the mother and infant can be harmful when mothers experience shame, stigma, or re-traumatization from well-intentioned community providers who have little understanding about the demands mothers in recovery experience.^{7, 21} In contrast, other mothers are afraid to express their needs and engage in services out of fear their child will be taken away or that any semblance of control that they have over their lives may be lost.⁷ Developing trust and relationships between clinical and community providers, including shared goals, understanding, and respect for each other’s contribution, are equally important to support therapeutic relationships with their patients.²²

Few pediatric clinicians, SUD treatment or social service providers have a full understanding of the many stresses postpartum mothers in recovery experience, and ironically, may themselves feel overwhelmed by the amount of work they are being asked to do on the family’s behalf.²³ Developing a shared understanding of the full complexity of a family’s needs is essential to providing more effective and efficient care that does not penalize mothers for failing to meet conflicting expectations from different providers. This requires training and dedicated resources for care coordination and treatment planning across the perinatal continuum by medical, social service, and SUD treatment providers. At the community level, interdisciplinary collaboratives bring together providers caring for families affected by SUD to meet face-to-face, develop relationships, and create shared goals.^{24, 25} Plans of Safe/Supportive Care, documents that list direct services and supports for parents and infants affected by substance use disorders, can be a useful tool to facilitate collaboration for individual families when thoughtfully developed and used beyond simply required documentation at delivery.²⁶

The Central Role of the Parent-Child Relationship

There continues to be a dichotomy between those who insist that the number one responsibility of a mother in recovery is to take care of herself compared with child health professionals who commonly communicate that a mother’s number one responsibility is to care for her infant.¹⁸ In our clinical experience, the parent and child’s health can be strengthened by focusing on both together. Yet emphasizing the parent-child relationship is much more than meeting the needs of the parent and child at the same time. Relationship-based care involves changing the way we perceive the dyad’s needs and the care we provide.^{27, 28} Pediatric care traditionally focuses on young children’s concrete needs and problems rather than mothers’ emotionally responsive care that builds early relational health critical to long-term child development.¹ Dyadic or relationship-based care encourages curiosity about the thoughts and emotions that parents and infants experience as they discover one another and how we can best support their new relationship. Prioritizing the parent-child relationship can promote empathy and responsive caregiving, the basis for all children to thrive.^{29, 30} For this reason, interventions that focus on strengthening this relationship are more effective than traditional behavioral or psychoeducational “how to” advice in shifting important outcomes such as improved child attachment and reduced rate of maternal relapse.^{27, 31} A clinician can provide this relationship-based support by eliciting and discussing the feelings, challenges, joys, and aspirations associated with parenting, thereby creating a space for the mother to reflect this new and often complex experience. With this reframing, the experience of motherhood and the parent-child relationship becomes a central focus of recovery. It also reinforces the importance of therapeutic relationships between providers and patients (beyond providing information) as a critical component of care for SUD-affected families. These relationships can serve as models for growth in the parent-child relationship.

Trauma-Responsive Care for Mothers and Providers

Many healthcare and community-based programs have now embraced trauma-responsive care as a way to strengthen provider-patient relationships. This approach assumes that a mother with SUD is more likely than not to have a history of trauma, helps providers recognize trauma symptoms, and acknowledges the role trauma may play in a mother’s life.³² Trauma-responsive care helps providers imagine a mother’s behavior in the context of past trauma,³³ for example a missed appointment could reflect the need to avoid conflict as a coping mechanism developed in prior relationships. It also prepares providers to respond to patients in ways that do not trigger trauma symptoms or elicit new traumatic experiences.^{33, 34} However, beyond families being served, front line clinicians and community providers may have personal trauma histories. Even without past trauma, they can experience secondary trauma when helping families cope with past events.

When providing trauma-responsive care for families, providers need to experience trauma-responsive supervision and support from their employers and supervisors as part of their organizational system. Without such explicit efforts, secondary trauma and burnout can be exacerbated by stressful work environments.¹³ We cannot ask providers to give their energy fully to the families they serve without ensuring their own emotional needs are being met. In truth, the strengthening of these parallel relationships from employer to provider, and provider to parent, is needed to provide optimal care for the parent-child relationship. This concept of parents and providers putting their ‘oxygen mask on first’ before caring for others, needs to be reflected in organizational structures and policies in order to begin to shift societal expectations that mothers must sacrifice their own needs as individuals and women in recovery in order to properly care for their child. As we have learned from healthcare research more broadly,^{35, 36} child health systems that nurture front line providers so they in turn can nurture mothers, especially those with SUDs, more effectively achieve their goals of nurturing the child.

Future Directions

We developed these three recommended areas for change prior to the rapid and ongoing restructuring of the healthcare system in the setting of the COVID-19 pandemic. Families affected by SUD will continue to be disproportionately harmed by the health, intrapersonal, and economic consequences of the pandemic. At this critical juncture, we must redouble our efforts to ensure that care for SUD-affected families incorporates principles of deepening clinical-community partnerships, prioritizing parent-child relationships, and creating trauma-informed systems to repair the unique emotional, physical, and financial impact that this sentinel event has had on us and our patients.