AAP Voices Blog

As a neonatologist, I’ve cared for hundreds of sick and premature babies. The Neonatal Intensive Care Unit (NICU) was never on any of the parents’ birth plans. That’s just not how the dream goes.

The NICU does not discriminate. This vulnerable population includes infants and families of every race, ethnicity, gender, sexual orientation, socio-economic status, age, physical ability, religious belief, political belief, or other ideology. I’ve seen them all.

Mental health doesn’t discriminate either, nor does substance use and addiction. The raging opioid epidemic proves this. Just as no parent imagines having a baby too ill or fragile to go home with them, none grow up fantasizing about having a substance use disorder.

I have seen infants born to the single unemployed urban woman who uses IV drugs and the married educated executive from the suburbs, and everything in between. Even within a uniform category of cases, I am astounded by the variability in how they are handled by child protective services and the final disposition of the child. Depending on the county and the case worker, actions range from the state taking custody immediately to family preservation services. Sometimes I agree, sometimes I disagree, but often am I perplexed and unable to predict the outcome.

Keeping families affected by substances together as they heal

All pediatricians have seen children affected by parental substance use disorders. We’ve all taken care of children in foster care or state custody, and we’ve seen the trauma that can result. Foster care is supposed to be the safety net for kids in imminent danger, but what is the safety net to prevent the need for foster care in the first place? And what if foster care is not in the best interest of the child, in which case it only adds to their trauma?

Many people assume that most foster care placements are due to abuse. The reality is that the majority (roughly 75%) of kids in foster care are there because of neglect, which often stems from issues such as parental substance use or unmet mental health needs. I am seeing many more substance-exposed babies admitted to the NICU, and many more placed in foster care.

Kansas and neighboring Missouri, where I practice, are among many states seeing a rise in children being placed in foster care. Parental substance use was a factor in 46% of foster care placements in Kansas and over 50% of placements in Missouri, according to the most recent statistics.

More than half of children placed in foster care return to their families at some point. So what happens to their parents during this time? Do they get the resources and treatment they need to address the root of the problem?

More importantly, what happens to the children during this time before they return to their family? If only there was a way to get families the care they need while keeping them together, putting the priority on family, first.

​“Foster care is supposed to be the safety net for kids in imminent danger, but what is the safety net to prevent the need for foster care in the first place? And what if foster care is not in the best interest of the child, in which case it only adds to their trauma?”

Making landmark reform a reality for families

The Family First Prevention Services Act is bipartisan, AAP championed legislation that was signed into law in 2018 and has the power to transform child welfare throughout the United States. This policy allows states to use federal funds previously limited to paying for foster care to prevent the need for foster care placement. By providing access to in-home services including substance use disorder treatment, mental health services (for parents and children), and intensive parenting education, families can heal together.

Prevention is at the heart of what pediatricians do. Through Family First, scientific, evidence-based interventions can be used to help avoid further trauma and the need for foster care while improving outcomes. Pediatricians know the potential effects of foster placement on child health and development. We’ve seen the long-lasting trauma of separation to both children and parents. Keeping families safely together while parents get treatment for substance use disorder and children receive trauma-informed care to address the impact of parental substance use represents the best evidence-backed approach. It can increase the likelihood of recovery for everyone.

The opioid epidemic adds urgency to the tenets of Family First, spotlighting mental health and the need to treat disorders of the brain like any other organ. It gives us the opportunity to discuss the importance of trauma-informed pediatric care. Most importantly, it highlights the importance of strong families in optimizing growth and development of children. Family First incorporates the best scientific evidence on child trauma, development, and attachment and offers states the tools to provide families in crisis the services they need.

However, while Family First has been signed into federal law, states have to act and allocate matching funds to implement it. Children need pediatricians to educate state legislators on why these changes in child welfare policy will benefit the health and well-being of the children and families you care for in your state. Without state action, children in your state will not benefit from these policies.

I've worked with my chapter here in Kansas to organize successful advocacy to encourage our state to implement this critical law. I am excited that in recognition of National Foster Care Month in May, AAP has developed a Family First Advocacy Toolkit and a May 1 advocacy day of action so that pediatricians can share their stories about why these policies matter for child health.

Family First is a landmark reform of federal child welfare law with the opportunity for states to better serve vulnerable children and families. As pediatricians, we have the power, responsibility and privilege to help ensure this needed reform is put into action.