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. Author manuscript; available in PMC: 2022 Jul 1.
Published in final edited form as: Child Youth Serv Rev. 2021 Apr 17;126:106021. doi: 10.1016/j.childyouth.2021.106021

Types of child maltreatment and child welfare involvement among opioid-using mothers involved in substance use treatment

Angela Moreland a, Carla Newman a, Kat Crum a, Funlola Are a
PMCID: PMC8415468  NIHMSID: NIHMS1698636  PMID: 34483418

Abstract

Although there is a significant link between maternal substance use and child maltreatment risk, extant literature has not investigated this link specifically among the growing number of parents abusing opioids. Underreporting of opioid use within child welfare presents further challenges in elucidating relations between maternal opioid use and child maltreatment. The purpose of the current study is to examine the link between maternal opioid use in women in substance use treatment and self-reported rates of child maltreatment and child welfare involvement of their children. We examined maternal substance use, severity of substance use, severity and type of child maltreatment of their children, and child welfare involvement across mothers who misuse opioids and misuse other substances using self-report surveys with 89 mothers. Results suggest similarities and differences among mothers who use opioids and other substances. Mothers who use opioids endorsed more significant and prolonged involvement with child welfare than mothers who use other substances. Participants did not endorse significant differences between rates of child maltreatment, and treatment engagement across groups. Given increased awareness of significant risks associated with opioid abuse, including greater risk for child maltreatment, a better understanding of its intersection with child welfare is necessary.

Keywords: child maltreatment, opioid use disorder, child welfare

1. Introduction

Maternal substance use is a significant risk factor associated with child maltreatment (Child Welfare Information Gateway, 2014; Dubowitz et al., 2011; Ondersma, 2002). An estimated 50% to 80% of abused and neglected children involved in the child welfare system have a parent with a significant substance use problem, which poses substantial safety risks for the child and family (Hall, Wilfong, Huebner, Posze, & Willauer, 2016; Semidei, Radel, & Nolan, 2001; Young, Boles, & Otero, 2007). Among reasons for child removal following child welfare involvement, parental drug abuse demonstrated the largest rate of increase (22.1% to 29.7%) from 2009–2014 (Young, 2016). Approximately 1 in 5 child fatalities have been associated with parental substance use (U.S. Department of Health & Human Services, 2018), and children living with a mother with a substance use disorder are twice as likely to have child maltreatment allegations substantiated (Carter & Myers, 2007; Freisthler, Kepple, Wolf, Curry, & Gregoire, 2017; Morris, Marco, Bailey et al., 2019). Once involved in the child welfare system, children of with mothers that have substance use concerns are less likely to reunify with mothers after being placed in foster care (Aguiniga, Madden, & Hawley, 2015; Bishop et al., 2000; Lloyd, Akin, & Brook, 2017), are placed in out-of-home care for longer durations (Barth, Gibbons, & Guo, 2006; De Bortoli, Coles, & Dolan, 2013), and have more negative outcomes in foster care than children of mothers without substance use concerns (Lloyd & Akin, 2014; Mirick & Steenrod, 2016).

While the link between maternal substance use and child maltreatment has been well-established, less is known about the relationship between maternal drug of choice and type of child maltreatment experienced by their children, especially when unreported to child welfare (Hogan, 2003; Slesnick, Feng, Brakenhoff, & Brigham, 2014). With the significant rise in opioid use over the past decade, literature has focused on mothers with opioid use concerns and the impact on the child and family. A comprehensive review of outcomes of children of mothers who use opioids indicated that children of mothers who use opioids displayed decreased academic, cognitive, and social functioning compared to other groups, although findings have been somewhat mixed (Peisch et al., 2018). Research has found strong associations of opioid-related hospitalization and opioid prescribing rates with rates of child maltreatment, substantiated child abuse reports, and child removals from the home due to abuse allegations (Ghertner et al., 2018; Morris et al., 2019; Quast et al., 2018,2019; Sumetsky et al., 2020). Given overlapping rates of maternal opioid use, child maltreatment, and child welfare involvement, the purpose of this study is to examine the link between maternal opioid use among women in substance use treatment and self-reported rates of child maltreatment and child welfare involvement of their children.

1.1. Opioid Use and Child Maltreatment

Compared to mothers who use other substances, mothers who use both prescription and non-prescription opioids are more likely to have suffered multiple adverse childhood experiences (ACEs) (Campaign for Trauma-Informed Policy and Practice, 2017). This is particularly concerning given that multiple ACEs can negatively affect parenting and increase the likelihood that the parent will engage child maltreatment against their own children (American Academy of Pediatrics, 2014). Results of a retrospective, population-based, cohort study indicated that children of mothers with opioid use disorders who were prescribed medications for addiction treatment (MAT) were at greater risk of experiencing poverty, unfavorable perinatal conditions, and parental health problems (Fang, Huang, Tsay, Chang, & Chen, 2018). In addition, findings from a 12-year study of children of mothers with opioid use disorder involved in MAT indicated that parental hospitalization, incarceration, death, and family disruptions were common (Fang et al., 2018; Haggerty, Skinner, Fleming, Gainey, & Catalano, 2008; Skinner, Haggerty, Fleming, Catalano, & Gainey, 2010). These hardships often limit access to social and health resources, impair parenting practices (e.g., supervision) (Fang et al., 2018; Jansson & Velez, 2011), and heighten their own children’s risk for child maltreatment (Smith, Smith, Cercone, McKee, & Homish, 2016; Spehr, Coddington, Ahmed, & Jones, 2017). Thus, in addition to direct opioid use, hardships associated with mothers who use opioids place children at further risk for child maltreatment.

1.2. Opioid Use and Child Welfare Involvement

As child welfare caseloads have increased nationally by 10% between 2012–2016 (Radel et al., 2018), recent research has sought to understand the impact of maternal opioid use on the child welfare system. Findings suggest that higher rates of opioid use disorders, drug overdose death, and opioid-related hospitalization were correlated with increased child maltreatment reports, child welfare involvement, and foster care entries (Hedegaard, Warner, & Miniño, 2017; Institute of Medicine and National Research Council, 2013; Radel et al., 2018; Sumetsky et al., 2020), which has not been found with stimulant and hallucinogen use (Radel et al., 2018) or alcohol-related disorders (Sumetsky et al., 2020). Child welfare administrators suggest the rise in foster care placement from 2013–2015 (397,000 – 428,000) is correlated with parental opioid use (Morton & Wells, 2017; Radel et al., 2018). Although researchers and child welfare administrators have suggested a significant relationship between the opioid epidemic and rise in child welfare caseloads (Quast, Storch, & Yampolskaya, 2018; Radel et al., 2018), accurate prevalence rates are difficult to obtain due to variations in assessing and reporting accurate rates of maternal substance use across state child welfare agencies. Therefore, many researches rely on anecdotal evidence or underrepresented child welfare prevalence rates to examine the relationship between opioid use and child maltreatment (Seay, 2015).

In geographic areas where opioid use was most prevalent, agencies reported a high rate of multi-generational substance abuse, creating a significant barrier to parents retaining custody of their children (Radel et al., 2018), and ensuring lower rates of reunification compared to parents with alcohol or cocaine use (Choi & Ryan, 2007; Grella, Needell, Shi, & Hser, 2009; Hall et al., 2016). These findings suggest that maternal substance use, specifically opioid use, is a significant factor in the growing number of families involved in the child welfare system, as well as the length of time children are involved in the system. Given the high overlap in opioid use rates and child welfare placements, recent research has focused on opioid use and foster care caseloads. Specifically, Taplin and Mattick (2015) found that, 63.7% of mothers enrolled in an opioid treatment program reported that one or more of their children had been involved in a report to child protective services (CPS), and 32.7% had at least one child placed in out-of-home care. Further, studies have reported increases in opioid use of up to 15% among child-welfare involved mothers (Mowbray et al., 2017), and opioid use has been associated with a 32% higher removal rate for child maltreatment (Quast et al., 2018).

Studies of women in substance use treatment have indicated that more than 50% of mothers have had a child welfare allegation against them (Conners et al., 2004; Grella et al., 2003), and that over 30% of mothers have had their child removed from care or lost parental rights prior to substance use treatment admission (Knight & Wallace, 2003; Schilling et al., 2004). While a significant percentage of women in substance use treatment programs have reports of child maltreatment reported against them and/or are involved in the child welfare system, studies have found that substance use treatment programs rarely provide services to address parenting or prevention of child maltreatment (Grella & Greenwell, 2004; Moreland & McRae-Clark, 2019).

Given the significant rise in parental opioid use in the United States, and the critical link between maternal opioid use, child maltreatment, and child welfare system involvement, further examination of these overlapping rates is essential, especially among women involved in substance use treatment programs. While research has examined the overlap of maternal opioid use, child maltreatment, and child welfare involvement, accurate rates of these overlapping variables are difficult to obtain given variation in reporting among child welfare agencies. Further, studies to date have not compared the type(s) of child maltreatment experienced by children of mothers who use opioids and those of mothers who use other substances, and have not examined these constructs among women involved in substance use treatment programs. The current study will investigate the association between maternal opioid use (prescription and non-prescription) among women involved in substance use treatment and self-reported rates of child maltreatment and child welfare involvement of their own children. In addition, the study will explore rates of engagement in trauma-focused treatment for children of mothers who use opioids and report that their children have experienced child maltreatment. Given research citing higher rates of child maltreatment and child welfare involvement among children of women who use opioids compared to other substances, we hypothesize that women who use opioids will report higher rates of child maltreatment and child welfare involvement of their children.

2. Method

2.1. Participants

Self-report surveys were completed by a sample of mothers (n=89) enrolled in a substance use treatment program in the Southeastern United States. Average participant age was 31.11 (SD = 7.06, range = 19–59) years. Participants reported their race/ethnicity as White (58%), African American (24%), Other (10%), Native American (5%), Hispanic (2%), or biracial (1%). The majority of participants were single or never married (89%) and had completed high school or 1–3 years of college (67%). The largest percentage of participants had a household income of less than $5,000 per year (47%), followed by $5,000 to $9,999 per year (18%); the remainder reported income of more than $10,000 per year. Forty-seven percent were receiving inpatient treatment, 9% were receiving intensive outpatient treatment, and 44% were receiving outpatient treatment. Forty-one percent (n=39) of women reported opioids as their primary substance. Descriptive information for the subpopulation of women who reported opioids as their primary substance can be found in Table 1.

Table 1.

Substance Use Frequencies over the Previous Three Months

Frequency Percent
Opioids Once or twice 2.6
Monthly 2.6
Weekly 20.5
Daily/almost daily 71.8
Other Substances
 Alcohol Once or twice 38.5
Monthly 12.8
Weekly 5.1
Daily/almost daily -
 Amphetamines Once or twice 15.4
Monthly 10.3
Weekly 7.7
Daily/almost daily 17.9
 Cannabis Once or twice 23.1
Monthly 28.2
Weekly 7.7
Daily/almost daily 10.3
 Cocaine Once or twice 20.5
Monthly 5.1
Weekly 17.9
Daily/almost daily 10.3
 Hallucinogens Once or twice 15.4
Monthly 2.6
Weekly 2.6
Daily/almost daily -
 Inhalants Once or twice 10.3
Monthly 2.6
Weekly -
Daily/almost daily -
 Sedatives Once or twice 15.4
Monthly 12.8
Weekly 10.3
Daily/almost daily 12.8
 Tobacco Once or twice 7.7
Monthly 5.1
Weekly 10.3
Daily/almost daily 74.4
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Note: As this subsample of mothers was involved in a treatment program targeting substance use, mothers reported not using the following substances at all over the previous three months: alcohol (41%); amphetamines (46.2%); cannabis (28.3%); cocaine (43.6%); hallucinogens (79.5%); inhalants (84.6%); opioids (2.6%); sedatives (48.7%).

2.2. Procedures

Participants were recruited from a substance use treatment program that provides integrated inpatient and outpatient services for women. The substance use treatment center is a single center located in an urban location that typically serves 330 patients through their programs. The demographics of the center are representative of the surrounding population, such that 35% of patients are African American and genders are represented fairly equally (55% women, 45% men). The population in the current study is representative of women who typically receive services at the substance use treatment center. Prior to recruitment, project staff attended a staff meeting at the treatment center, where the study and procedures were presented and described. Project staff then described the study to women enrolled in the substance use treatment program and invited them to contact study staff to participate. Study staff were also invited to describe the study prior to patient participation in group therapy, and to set up a recruitment table in the clinic. Enrollment was open to all women enrolled in the inpatient or outpatient programs at the substance use treatment center who had a child between ages 0–18. During the recruitment period, 171 women were enrolled in services at the substance use treatment center and 126 women met inclusion criteria of having a child between ages 0–18. Of the 126 women who met criteria, 99 women were presented with information about the study (79%; others were not recruited because they did not attend groups during the recruitment period) and 89 women completed the survey (90% of those recruited). Interested participants completed informed consent and were able to ask questions regarding the study before enrolling. The length of time between being informed of the study and study enrollment was less than 48 hours for all participants. Once enrolled, measures were completed in a private room at the clinic and participants were compensated $30 for participation. To control for social desirability, the participants were informed that no information about involvement or responses would be disclosed to the substance use treatment program and no substance use treatment staff were allowed in the private room where the surveys were being conducted. All procedures were approved by the University IRB.

2.3. Measures

Mothers completed a self-report survey, which included measures on sociodemographic characteristics, maternal substance use and opioid use (prescription and non-prescription), child maltreatment against their children (e.g., physical abuse, sexual abuse, witnessing violence at home or in the community, traumatic death, etc.), and questions regarding child welfare involvement.

2.3.1. Substance use

Substance use was measured via self-reported responses on the Alcohol, Smoking, and Substance Involvement Screening Test (WHO ASSIST Working Group, 2002), which asks about lifetime use of commonly used substances within the following 10 categories: tobacco products, alcohol, cannabis, cocaine, stimulants, inhalants, sedatives/hypnotics, hallucinogens, opioids, and “other” drugs. The ASSIST collects drug-specific information about lifetime use and current severity through a series of questions: “In the past three months, how often have you used (drug)?”; “During the past three months, how often have you had a strong desire or urge to use (drug)?”; “During the past three months, how often have you failed to do what was normally expected of you because of your use of (drug)?”; “Has a friend or relative or anyone else ever expressed concern about your use of (drug)?”Responses were rated on a 5-point scale, “never,” “once or twice,” “monthly,” “weekly,” or “daily or almost daily.” The last item, “Have you ever used any drug by injection?” assessed responses on a 3-point scale, “no, never;” “yes, in the past 3 months;” or “yes, but not in the past three months.” Specifically, ASSIST has shown to have excellent internal consistency (a =.85) and high test-retest reliability (k= .71) (WHO ASSIST Working Group, 2002). Internal consistency in the current study was adequate (α=.75). Participants were also asked one question about their primary substance that is used. Participants in the opioid use subgroup were those who reported opioid use as their primary substance being used (n = 44) and others were included in the substance use comparison group (n = 45).

2.3.2. Opioid use severity

The Current Opioid Misuse Measure (COMM) is a 17-item measure designed to assess aberrant behaviors associated with opioid misuse, such as: obtaining additional opioids from other doctors or ER; taking medication that belongs to someone else; taking more opioids than prescribed; using opioids for alternative reasons (other than the prescribed purpose); consuming opioid medication via alternative route (e.g., snorting). Responses were rated on a 5-point scale of “never,” “seldom,” “sometimes,” “often,” or “very often” and summed to detect the severity of misuse. COMM scores have demonstrated high internal consistency (α=.86) and test-retest reliability (ICC=.86) (Butler et al., 2007). Internal consistently in the current study was excellent (α=.96).

2.3.3. Child maltreatment among children

Participants reported on rates of child maltreatment of their children via parental report using the Child Abuse and Trauma Scale (CATS;(Sanders & Becker-Lausen, 1995), which is designed to assess 15 potential child maltreatment events and one item regarding other extraordinary stressful events. Responses to events are “yes” or “no.” The last 20 items measured trauma symptoms on a 5-point frequency scale ranging from “never,” “once in awhile,” “half the time,” to “almost always.” The CATS has shown excellent test-retest (r=.89) and internal consistency of (α=.90) (Burgermeister, 2007),as well as in the current study (α=85).

In the current paper, we selected items related to child physical abuse, sexual abuse, witnessed domestic violence, witnessed community violence, the sudden or violent death of a loved one, and direct violent victimization (other than physical abuse) to represent rates of child maltreatment. When applicable, polyvictimization (i.e., experiencing multiple types of victimization within each category) was measured by summing the dichotomous scores from these variables. The following exposure scores were created: (i) family physical abuse; (ii) sexual abuse; (iii) domestic violence; (iv) community violence; (v) sudden/violent death of a loved one; and (vi) direct violent victimization (other than physical abuse).

2.3.4. Treatment Engagement

A single question was used to assess whether participants’ children had ever received psychosocial treatment. Specifically, participants responded “yes” or “no” when asked, “Has your child ever been involved in therapy?”

2.3.5. Child welfare involvement

Rates of child welfare involvement due to child maltreatment against their child were assessed with the following questions: “Has a report ever been filed to child protective services (DSS) on you or your child?”; “If yes, what was the report?” (e.g. child physical abuse, child sexual abuse, witnessing domestic violence, neglect, substance use, or “other”); “Were the allegations founded or not founded?”; “Has your child ever been removed from your care from DSS?”; “Where was the child placed?”; “How long was your child out of the home?”; and “Is your child currently out of the home?” For these questions, parents reported on any children between ages 0 to 18.

2.4. Data Analysis

Descriptive statistics provided information on: (1) opioid and other substance use; (2) child maltreatment rates and types among children of mothers who use opioids; and (3) child welfare system involvement among mothers who use opioids. Chi-square and t-tests explored associations between opioid versus other substance use, child maltreatment, child welfare system involvement, and treatment engagement. To account for alpha inflation given multiple statistical tests were conducted, we used the adjusted p-value (Bonferroni) to for alpha inflation on all tests.

3. Results

3.1. Descriptives

Table 1 presents participant-reported frequencies of various substances in the past 3 months. There were no differences in findings among type of treatment being received (inpatient versus outpatient). Among mothers who use opioids as their primary or secondary substance of choice, opioid misuse severity scores on the COMM ranged from 4–68, with an average score of 37.31 (SD = 18.87). High-risk opioid use scores were endorsed by 76.9% of the sample (≥ 9 on the COMM). Child posttraumatic stress symptom severity of the children was significantly correlated with mothers’ sedative misuse severity (r = .41, p = .03), and marginally correlated with mothers’ opioid (r = −.37, p = .08) and hallucinogen (r = .32, p = .10) misuse severity, but was not correlated with misuse severity for other substances (ps = .17 - .61).

3.2. Child Maltreatment

Table 2 presents percentages and difference tests for child maltreatment variables. Mothers who use opioids reported that their children had experienced a range of child maltreatment types, including: physical abuse (16.7%); sexual abuse (13.9%); direct violent victimization other than physical or sexual abuse (30.6%); witnessing domestic violence (36.1%); witnessing community violence (30.6%); and the sudden or violent death of a loved one (33.3%). Compared to mothers who use other substances, there were no significant differences in child maltreatment types reported by mothers who use opioids (ps=.62 - .97). Engagement in trauma-focused treatment did not differ between children whose mothers used substances in general versus opioids (Χ2 (1) = 1.16, p = .28). Among mothers who use opioids, 27.8% reported that their child had engaged in psychosocial treatment, versus 36.7% among mothers with other substance use.

Table 2.

Percentages and difference tests for child maltreatment and welfare involvement variables.

OUD SUD Difference Test
Interpersonal Trauma Type
Family physical abuse 16.7% 21.4% Χ2 (1) = 0.19, p = .66
Sexual abuse 13.9% 17.2% Χ2 (1) = 0.001, p = .97
Domestic violence 36.1% 39.3% Χ2 (1) = 0.04, p = .84
Community violence 30.6% 31.0% Χ2 (1) = 0.02, p = .88
Sudden/violent death 33.3% 32.1% Χ2 (1) = 0..24, p = .62
Direct violent victimization 30.6% 38.6% Χ2 (1) = 0.17, p = .68
Child Welfare Involvement
Removed from care ever 36.1% 38.8% Χ2 (1) = 0.14, p = .71
Time spent out of home t (37) = −2.55, SE=.79, p = .01
 Less than 1 year 28.6% 56.3%
 1–1.5 years 35.7% 12.5%
 2 years 28.6% 6.3%
 3 years 7.1% 18.8%
 Permanent - 6.3%
Removed from home currently 22.2% 26.5% Χ2 (1) = 0.26, p = .61
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Note: Direct violent victimization refers to violent victimization other than family physical abuse and sexual abuse.

3.3. Child Welfare Involvement

Table 2 presents percentages and difference tests for child welfare involvement variables. When examining self-report data of child welfare involvement, results indicated that 55.6% of children of mothers who use opioids had prior or current CPS involvement, 36.1% had ever been removed from the home by CPS, and 22.2% were currently removed from the home by CPS. The majority of children of mothers who use opioids who had been removed from the home were removed for 12–24 months (64.3%). Compared to parents that used other substances, percentages of children who had ever been removed from care (38.8%) or were currently removed from care (26.5%) were not significantly different from mothers who use opioids (ps = .61 - .71). However, children of substance-using parents were more likely to never be removed from the home (44.9%) or removed for less than one year (56.3%). This resulted in a significant difference in time removed from care between mothers who use opioids versus mothers using other substances (p = .02).

4. Discussion

Given the significant rise in maternal opioid use in the United States, and the critical link between maternal opioid use, child maltreatment of their children, and child welfare system involvement, this study filled an important gap in the literature by examining these overlapping rates. While studies have examined the overlap in maternal opioid use and child welfare involvement, studies to date have not examined the type(s) of child maltreatment experienced by children of mothers who use opioids enrolled in a substance use treatment program, and how this compares to use of other substances. Additionally, we investigated rates of child welfare involvement, types of involvement, and length of time removed from home among mothers who use opioids compared to other substances, enrolled in a substance use treatment program.

Overall, mothers who use opioids reported significant levels of opioid use, with over 75% endorsing high-risk scores. Consistent with existing literature, child maltreatment rates were high among mothers with both opioid misuse and other substance misuse (Carter & Myers, 2007; Freisthler et al., 2017). Contrary to hypotheses, when comparing child maltreatment among mothers who use opioids versus other substances, rates of all types of child maltreatment were similar. This finding indicates that risk for child maltreatment may be similar for children of mothers who use opioids versus other substance use. Finally, similar to findings regarding child maltreatment, treatment engagement rates were not significantly different between mothers who use opioids and other substance use.

When examining child welfare involvement, findings indicated that children of mothers who use opioids versus other substance use had similar rates of child welfare involvement— contrary to hypotheses. However, children of mothers with general substance use were more likely to never have been removed from the home. In addition, children of mothers who use opioids were typically removed from the home for longer periods of time than children of mothers with other substance use concerns. This is consistent with existing literature citing anecdotal evidence related to increased opioid prescription rates and increased child removal rates (see Quast et al., 2018) and adds evidence for the difference in length of removal of children from mothers who use opioids versus other other substance use. One hypothesis for this difference in time that children were removed from the home may be due to stigma around use of medication assisted treatment, which is the gold-standard treatment for OUD. Specifically, studies of healthcare provider attitudes have found significant stigma and resistance to providing medication assisted treatment, due to antiquated belief systems that the patient is “replacing one drug with another drug” by being prescribed medication assistant treatment (Moreland et al., 2020). In one study, 40% of substance use treatment programs reported resistance from community providers to prescribe medication assisted treatment, although it is the standard of care for OUD (Moreland et al., 2020). Given the stigma among substance use treatment providers, it is likely that child welfare services workers, who are even less familiar with substance use treatment options, may have the same stigma and thus, keep children removed for longer periods of time when parents are prescribed medication assisted treatment.

4.1. Clinical Implications and Considerations

Findings of similar child maltreatment types and rates among mothers who use opioids versus other substance use have important clinical implications for addressing child maltreatment risk in treatment settings. Research has made recommendations for incorporating child maltreatment prevention and related parenting curriculum into substance use treatment programs (Marsh, Smith, & Bruni, 2011). Traditionally, when treatment programs have incorporated maltreatment prevention curriculum, it is during inpatient or intensive outpatient settings. In recent years MAT to address opioid misuse, often delivered in outpatient treatment settings, has reduced the number of mothers engaging in inpatient or intensive outpatient treatment. While this allows mothers to engage in other activities that are beneficial to self- and family-improvement, such as maintaining a job and being active in the child’s life, it is important to identify creative ways that child maltreatment prevention curriculum can be incorporated into these programs. This is especially crucial given our findings, which suggest that the risk is similar for mothers who use opioids and who use other substances.

In addition, the findings that children of mothers who use opioids remain in the child welfare system significantly longer than children of mothers using other substances has critical treatment implications. Due to strong stigmas against MAT, the gold standard for treatment of opioid misuse, one explanation may be that child welfare workers do not consider parents to be substance-free during MAT. Future research should examine this more closely and investigate ways to incorporate psychoeducation about opioid misuse and MAT into the child welfare system. Further, collaborations across systems of care could increase knowledge, assessment, and treatment referrals between substance use treatment programs and child welfare. In addition, it may be beneficial to incorporate child maltreatment prevention or parenting interventions and education into opioid treatment settings to address factors related to removal from the home, as well as increase likelihood that the child will not be removed as long from the home if they are already removed. Several time-limited and user-friendly parenting education programs have been found efficient and appropriate for high-risk parents, which should be examined for use specifically with opioid-using parents.

4.2. Limitations and Future Directions

The current study is not without limitations. The study relied on self-report data from participants, who may have underreported child maltreatment and substance use due to social desirability considerations. However, the study relied on participants currently enrolled in a substance use treatment program that typically received referrals from child welfare and thus, the program would already be aware of child welfare involvement and social desirability may have been less of a concern, as these individuals were actively seeking assistance with their substance use and therefore may be less influenced by social desirability. Second, the study was conducted with women enrolled in a substance use treatment center and results cannot be generalized to all women who use opioids or other substances. Third, the study did not obtain information on referral source, so differences between those mothers referred from child welfare versus entering for other reasons could not be assessed. In addition, women with opioid use who are receiving MAT cannot be generalized to women using opioids that are not receiving treatment that includes MAT. Future studies should examine these relationships among women in additional settings and utilize multiple methods in addition to self-report. The current study analyses are preliminary and should not be overgeneralized beyond the study context.

Despite these limitations, the current study addresses a crucial gap in substance use literature and suggests critical future research directions. We suggest that future studies continue to elucidate the unique treatment needs of mothers with varying types of substance misuse. Given the high maltreatment risk among children of mothers who use opioids and other substances, it is especially important to consider comprehensive substance use treatment models that integrate child maltreatment prevention. Further, given increasing acceptance of harm-reduction models in substance use treatment (e.g., MAT), it is important to consider implications for aspects of treatment that have previously been provided through more traditional substance use treatment models, such as parenting skills or child maltreatment prevention. Some research has identified comprehensive service models integrating child welfare and substance abuse treatment at the systems, state, and services level (Marsh et al., 2011) to underscore the importance of cross-collaboration across these treatment domains. Future research should continue to assess the unique needs of mothers who use opioids and possible intersections of child welfare and substance use treatment systems, considering the present findings.

4.3. Conclusions

The present study examined child maltreatment, child welfare involvement, and child treatment engagement among mothers with opioid misuse and misuse of other substances. The study adds to burgeoning literature identifying unique needs of mothers who use opioids and their children, given increasing national opioid abuse rates. Given strong evidence of associations between maternal substance use and child maltreatment risk, we highlight important clinical implications and future research directions.

Highlights.

  • Literature has not linked opioid use disorder with child maltreatment risk.

  • Results suggest similarities and differences among mothers who use opioids and other substances.

  • Mothers who use opioids endorsed more significant and prolonged involvement with child welfare than mothers who use other substances.

  • Participants did not endorse significant differences between rates of child maltreatment, and treatment engagement across groups.

Acknowledgments

Funding: This study was supported by grant 5K12DA031794–03 to support the first author.

Footnotes

I do not have any conflicts of interest to report.

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