Prenatal substance exposure can have physical, cognitive, and socio-emotional consequences across the child development continuum — from infancy through adolescence to young adulthood. Effects vary depending on a variety of factors, including exposure to multiple substances, the timing of exposure, and the type of substance to which the fetus was exposed.¹

Child protection agencies report that parental substance use was a factor for out-of-home placement for more than a one-third (35%) of children entering foster care. Further, studies find that up to 90% of child welfare cases involve families affected by substance use disorders.²

A 2018 research study found increases in drug-related hospitalizations and overdose deaths positively align with an increase across the child welfare caseload, noting that a 10% increase in drug overdose deaths in a county corresponded to a 4.4% increase in children entering out-of-home care.³ Of particular concern, the number of infants entering foster care increased 25% from 2011 through 2018.⁴ While the number of children entering foster care increased for other age groups in the same time period, the increase of infants entering care was almost 13 times as much the increase in placements for other age groups. The large increase of infants entering care is largely attributed to parental substance use disorders.

While a parent’s drug or alcohol use may be cited as a factor for children entering foster care, it is important to remember that substance use disorder is a disease of the brain that can be effectively treated and managed. It is most important to understand that parental substance use alone never should be the primary determination behind a child removal decision, and neither should the presence of prenatal substance exposure in an infant. Instead, decisions on family separation must be based on an assessment of how substance use disorder within a family is affecting child safety. Communities can implement several strategies, including implementing Plans of Safe Care, to ensure that infants affected by prenatal substance exposure can remain safe with their families. These strategies provide the parents or caregivers affected by substance use disorder the services they need to become healthy while simultaneously providing care to the infants to mitigate the effects from the exposure. This brief highlights evidence-based practice and policy strategies to prevent or mitigate the effects of prenatal substance exposure and support families across three developmental stages: infancy and early childhood, primary school age, and adolescence and young adulthood. For more information on interventions, see: What are some evidence-based interventions to prevent and mitigate the effects of prenatal substance exposure?

Infancy and early childhood

Infants with prenatal substance exposure must be screened for developmental delays and engaged in services to mitigate the potential effects of exposure. Services include early intervention and therapeutic support to promote parent-child bonding and attachment. Screening at well-baby and well-child check-ups, or at other points of engagement such as early childhood programs, help ensure identification of infants and young children who would benefit from these early intervention services.

Screening and referral to early intervention services

The American Academy of Pediatrics recommends all infants with substance exposure receive a referral to early intervention services and developmental screenings. There are two primary ways of accessing services:

• Children, adolescents, and young adults up to age 21 enrolled in Medicaid are eligible for a variety of services under the Early and Periodic Screening, Diagnostic and Treatment benefit. Services include screening and assessment for developmental delays and mental health.
• Part C of the Individuals with Disabilities Education Act (IDEA) requires all infants and young children (ages 0-3) involved in substantiated child maltreatment cases be referred to early intervention services for developmental delay screening and other supports. Eligibility for IDEA Part C varies by state. Infants with prenatal substance exposure may be eligible under the “at risk infant or toddler” category.^5,6 In some states, infants diagnosed with neonatal abstinence syndrome are automatically eligible. Infants who need services sometimes may not meet the state-specific eligibility requirements, demonstrating the importance of ongoing screening and reassessment for developmental delays throughout childhood.

Effective interventions across developmental stages

There are a number of evidence-based parent-child interventions that have demonstrated effectiveness among families affected by substance use disorders. As of April 2023, 23 family-centered, parent-child interventions have been approved under the Title IV-E Prevention Services Clearinghouse, including:

Families

• START (Sobriety Treatment and Recovery Teams) is a specialized service delivery model that has been shown, when implemented with fidelity, to improve outcomes for children and families affected by parental substance use and child maltreatment. The model uses a variety of strategies to promote collaboration and systems-level change within and between child protection agencies, substance use and mental health treatment providers, the judicial system, and other family-serving entities.

Infants and Toddlers

• SafeCare is a program for children ages 0-5 at risk of abuse and neglect, as well as their parents and caregivers. It helps parents recognize and respond to children’s cues and develop other parenting skills.
• The Incredible Years® – Toddler Basic Program is a group-based program designed to strengthen parent-child attachment and is designed for parents with toddlers ages 1 to 3.

School-Age Children

• Parent-Child Interaction Therapy seeks to improve the quality of the parent-child relationship and is for children ages 2 to 7 and their parents or caregivers.
• Incredible Years® – School Age Basic Program can be offered as a group-based prevention or treatment program designed for parents of children ages 6 to 12. It aims to strengthen parent-child interactions and attachment, and parents’ abilities to promote children’s social, emotional, and academic development.
• Multisystemic Therapy – Building Stronger Families is designed for families with children ages 6 to 17 who come under the guidance of child protective services as a result of parental substance use disorders. Comprehensive family services including case management. Clinical services are provided in a team-based approach.

Adolescents

• Multidimensional Family Therapy focuses on adolescents and young adults with substance use and mental health disorders. It is an integrated therapy model that incorporates parents, families, and community partners, including the child protection agency. The goals are to help adolescents and young adults reduce substance use, stabilize their mental health, and develop coping and communication skills. The therapy also aims to improve parenting skills, parent-child attachment, and family communication.

Additional interventions not currently approved by the Title IV-E Prevention Services Clearinghouse:

• The Families Moving Forward Program incorporates cognitive behavioral therapy, motivational interviewing, and caregiver support and coaching. It is a promising practice for children with a fetal alcohol spectrum disorder and their families.
• Celebrating Families! offers prevention and intervention to promote family healing and improve family relationships. It is a family-inclusive, trauma-informed, skill-building program for families affected by parental substance use disorders with infants and children up to 17 years.
• Nurturing Parenting Program for Parents and their Infants, Toddlers, and Preschoolers and Nurturing Parenting Program for Parents & Their School Age Children 5 to 11 Years are family-centered interventions for parents with goals that include promotion of nurturing parenting skills and prevention of child abuse and neglect.
• The Incredible Years® – Parents and Babies Program and Incredible Years® – Preschool Basic Program are group-based programs that serve parents and their infants (0 to 12 months) and children (ages 3 to 6). The goals of the interventions include: strengthening parents’ abilities to provide a safe environment for their infants and children; helping parents and children form secure attachments; and encouraging development of children’s social, emotional, and self-regulation skills.
• Adolescent-Focused Family Behavior Therapy is provided within a family context for adolescents with substance use disorders and co-occurring issues such as conflict, depression, child maltreatment, trauma, noncompliance, or risky sexual behavior.

Primary school-aged children

Children with prenatal substance exposure require screening and interventions for a wide array of developmental delays, and socio-emotional and educational challenges. Screening must be conducted with validated, age-appropriate assessment tools and be followed with engagement in appropriate services.

Children must receive ongoing screenings as the effects of prenatal substance exposure may emerge at different points in childhood, or they may be missed (or misdiagnosed) in prior assessments. For example, fetal alcohol spectrum disorder is difficult to diagnose in children under age 3 because higher-level cognitive functioning effects often do not reveal themselves until school age.⁷ The Ages and Stages Questionnaire assesses the development of children between 1 month old and age 5½, and the Child Behavior Checklist identifies emotional and other issues in children and adolescents. For more information, see: Understanding Fetal Alcohol Spectrum Disorders: Child Welfare Practice Tips.

Special education services

Some interventions necessary to mitigate the physical and developmental delays caused by prenatal substance exposure can be accessed through Part B of the Individuals with Disabilities Education Act. Part B funds free services through the public school system for students ages 3 to 21 who have developmental disabilities. Services include special education and related supports — such as physical, occupational, and speech therapy — as well as supplementary aids and services. Children who qualify for special education services receive an Individualized Education Plan, which details the needs and special education services to be provided to each child. Children who do not quality for services under Part B may be eligible for special help in a regular classroom setting under Section 504 of the Rehabilitation Act of 1973.

Adolescents and young adults

Adolescents affected by prenatal substance exposure are at an increased risk for mental health concerns and other challenges, including involvement with the justice system. They also are at an increased risk for developing their own substance use disorder.^8,9,10 Adolescents who age out of foster care without a permanent home are at even greater risk for a variety of harms. These harms are magnified for youth affected by prenatal substance exposure or parental substance use.

Substance use disorder prevention and intervention services must be attuned to the diverse developmental needs of adolescents, particularly specialized interventions for those who age out of foster care.¹¹ Several long-term studies show that substance use disorder prevention and early intervention programs reduce risky behavior, promote protective factors, increase access to school- and community-based resources, and prevent the development of many social and health problems. The benefits of these programs continue through adolescence and into young adulthood and even adulthood. Consistent with adult interventions, services for adolescents require individualized prevention, treatment and recovery services, and benefit from a strengths-based approach.

Screening for substance use and mental health disorders

Screening, Brief Intervention, and Referral to Treatment is an effective method for identifying substance use disorders and engaging adolescents in treatment.¹² For more information on this intervention, see: SAMHSA’s Advisory: Screening and Treatment of Substance Use Disorders Among Adolescents.

Family-centered treatment

Effective, comprehensive substance use disorder treatment for adolescents combines therapy and other services to meet their specific needs and may include cognitive-behavioral therapeutic approaches, family-based approaches, integrated treatment for co-occurring disorders, medication-assisted treatment, and recovery support services.

Family-centered therapy approaches can help identify family-based risk factors and concerns that may contribute to adolescent substance use disorder.¹³ Research shows family-based models can produce positive outcomes for adolescents, including reductions in alcohol and drug use and involvement with criminal justice systems.^14,15 An important component of treatment is to have adolescents identify adults who are meaningful in their lives, including extended family, older siblings, and adult mentors, so professionals can work to preserve and enhance these supportive relationships.

Peer-based recovery support services allow adolescents in recovery to share their experiences with peers, provide mutual support to each other, and support a substance-free lifestyle. Mutual-help groups, such as 12-step programs, can provide ongoing support and improve outcomes for adolescents. Alateen is a mutual-help group for adolescents of parents with substance use disorders and provides opportunities to build a support system. An Alateen mobile app and other resources are available for adolescents ages 13 to 18.

1 Behnke, M. & Smith, V. C. (2013). Technical Report. Prenatal substance abuse: Short and long-term effects on the exposed fetus. American Academy of Pediatrics, 131(3), e1009-e1024.
2 Seay, K. (2015). How Many Families in Child Welfare Services Are Affected by Parental Substance Use Disorders? A Common Question that Remains Unanswered. Child Welfare. 2015;94(4):19-51. PMID: 26827475; PMCID: PMC4894838.
3 Radel, L., Baldwin, M., Crouse, G., Ghertner, R., & Waters, A. (2018). Office of the Assistant Secretary for Planning and Evaluation U.S. Department of Health and Human Services. Research Brief: Substance Use, the Opioid Epidemic, and the Child Welfare System: Key Findings from a Mixed Methods Study.
4 Crouse, G., Ghertner, R., Madden, E., & Radel, L. (2021). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services: Foster Care Entry Rates Grew Faster for Infants than for Children of Other Ages, 2011–2018.
5 At-risk infant or toddler is described in the Code of Federal Regulations, Part 303, Early Intervention Program for Infants and Toddlers with Disabilities as “an individual under three years of age who would be at risk of experiencing a substantial developmental delay if early intervention services were not provided to the individual. At the State’s discretion, at-risk infant or toddler may include an infant or toddler who is at risk of experiencing developmental delays because of biological or environmental factors that can be identified (including low birth weight, respiratory distress as a newborn, lack of oxygen, brain hemorrhage, infection, nutritional deprivation, a history of abuse or neglect, and being directly affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure).”
6 National Archives and Records Administration. (2022). Code of Federal Regulations, Title 34, Subtitle B, Chapter III, Part 303 Early Intervention Program for Infants and Toddlers with Disabilities.
7 Olson, H. C., Jirikowic, T., Kartin, D., & Astley, S. (2007). Responding to the challenge of early intervention for fetal alcohol spectrum disorders. Infants & Young Children, 20(2), 172-189.
8 Bailey, J.A., Hill, K.G., Oesterle, S., & Hawkins, J.D. (2006). Linking substance use and problem behavior across three generations. J Abnorm Child Psychol. 34(3):263–82
9 Lambert, B.L., Bann, C.M., Bauer, C.R., Shankaran, S., Bada, H.S., Lester, B.M., Whitaker, T.M., LaGasse, L.L., Hammond, J., & Higgins, R.D. (2013). Risk-taking behavior among adolescents with prenatal drug exposure and extrauterine environmental adversity. J Dev Behav Pediatr. 2013 Nov-Dec, 34(9):669-79. doi: 10.1097/01.DBP.0000437726.16588.e2.
10 Min, M.M., Minnes, S., Yoon, S., Short, E.J., & Singer, L.T. (2013). Self-Reported Adolescent Behavioral Adjustment: Effects of Prenatal Cocaine Exposure. Journal of Adolescent Health, 55 (2014): 167-174.
11 Bailey, J.A., Hill, K.G., Oesterle, S., & Hawkins, J.D. (2006). Linking substance use and problem behavior across three generations. J Abnorm Child Psychol. 34(3):263–82
12 Hinckley, J.D. & Riggs, P. (2019). Integrated treatment of adolescents with co-occurring depression and substance use disorder. Child and Adolescent Psychiatric Clinics of North America, 28(3), 461-472.
13 Substance Abuse and Mental Health Services Administration. (2021). Screening and Treatment of Substance Use Disorders among Adolescents. Advisory. Publication No. PEP20-06-04-008.
14 Henderson, C.E., Hogue, A., & Dauber, S. (2019). Family therapy techniques and one-year clinical outcomes among adolescents in usual care for behavior problems. J Consult Clin Psychol, 87(3), 308-312. doi: 10.1037/ccp0000376.
15 Hogue, A., Dauber, S., Henderson, C.E., Bobek, M., Johnson, C., Lichvar, E., & Morgenstern, J. (2015). Randomized trial of family therapy versus nonfamily treatment for adolescent behavior problems in usual care. J Clin Child Adolesc Psychol,44(6), 954-69. doi: 10.1080/15374416.2014.963857.