This month, the Administration for Children and Families announced that three medications for opioid use disorder (MOUD) are now rated as Well-Supported under the Title IV-E Prevention Services Clearinghouse. The result of a new “fast-track process” for reviewing FDA-approved treatments, this policy change reflects growing recognition in our field that substance use disorders are deeply intertwined with child welfare system involvement.
It also takes steps to address the imbalance between the robust evidence base on substance use treatment and the relatively limited number of such programs approved by the federal clearinghouse for child welfare prevention services.
But this policy shift should prompt a broader consideration of our role as a child welfare community in ensuring families have access to substance use treatment. If we are serious about prevention, family stability and reducing removals, we need to step beyond our traditional child welfare lane and advocate more forcefully for investment in treatment systems overall, particularly family-centered treatment approaches.
Substance use disorders are a central driver of child welfare involvement. Parental substance use is a condition associated with removal for nearly 40% of children entering foster care each year, and that share has risen steadily since 2000. Even that figure likely understates the scope of the issue: state variation ranges from roughly 5% to nearly 70%.
This trend is especially pronounced for young children. Infants account for nearly 20% of entries into foster care, and children ages zero to five make up over one-third of the foster care population. More than half of children under age one who enter care have parental substance use associated with their removal.
This is not just a child welfare problem — it is a treatment capacity problem. Substance use disorders are treatable, and recovery is possible. But outcomes depend heavily on timely access and continuity of care. In the United States, most people who need treatment don’t get it. According to the National Survey on Drug Use and Health, only about 20% of people who needed substance use treatment received it in the past year. The gap is often wider for parents, because the treatment systems are rarely designed around caregiving realities such as child care, transportation with children and stable housing.
All of this means child welfare repeatedly finds itself responding to untreated addiction, even though it was never designed to serve that function. As a result, these cases are among the most complex agencies confront.
Dr. Nora Volkow, the director of the National Institute on Drug Abuse has observed that many individuals who struggle with addiction start using during adolescence, when brain circuits related to emotion and sensation seeking mature more quickly than those responsible for judgement and inhibition. Parents often come to the attention of child welfare at the very moment when accumulated instability has eroded the executive functioning skills required to comply with case plans and court mandates. By the time a child welfare agency is involved, it must manage the consequences of untreated addiction with tools designed to assess child risk — not diagnose and support recovery.
The clearinghouse approval of MOUDs helps address this misalignment at the margins. It creates a pathway for some parents whose children are at imminent risk of entering foster care to access evidence-based treatment. But it also underscores the limits of relying on child welfare policy to compensate for broader failures in how treatment is financed and delivered.
We already know effective models for families at risk of child welfare involvement who are affected by substance use. These include Sobriety Treatment and Recovery Teams (START), Family Treatment Courts and therapeutic approaches such as contingency contracting and motivational interviewing. These models allow parents to receive substance use treatment while their children remain safely with them and receive developmentally appropriate services of their own. They strengthen attachment, reduce trauma, improve treatment retention and are associated with better child safety outcomes.
But few such approaches have gained nationwide traction. A 2019 Volunteers of America survey identified just 363 programs nationwide providing family residential SUD treatment. There are federal programs that support testing and expanding substance use treatment, but they are modest in size.
The Family First Prevention Services Act was intended to build on this evidence and expand states’ ability to connect families to services before a foster care removal becomes inevitable. In practice, the law has both advanced prevention and revealed structural constraints. Much of the strongest evidence on treatment was not developed with child welfare outcomes as the primary endpoint, creating barriers to clearinghouse approval for even gold standard programs. Financing remains fragmented across systems with different goals, eligibility rules and accountability structures.
There is also a tension that both child welfare and treatment professionals understand well. Child welfare is a system with extraordinary authority over family life. When services are offered through a system that can remove children, questions of trust and voluntariness are unavoidable. Whether MOUD becoming Well-Supported translates into improved outcomes will depend on how states engage treatment providers, people with lived experience and community partners to ensure access to these medications before a crisis escalates.
The deeper challenge lies upstream. Child welfare continues to absorb the consequences of gaps in substance use treatment, housing and mental health systems. When families cannot access treatment early, when family-centered options do not exist or when programs have long waitlists or narrow eligibility, the consequences surface in child welfare.
Child welfare leaders have a stake in the strength of the substance use treatment system, and that stake should shape our collective agenda. State child welfare agencies can partner with health authorities to jointly assess gaps in family-centered capacity and elevate those gaps in policy conversations. National child welfare advocates can more explicitly frame treatment access as a child welfare issue and incorporate it into federal policy agendas; the National Coalition for Child and Family Well-Being has already done so. Philanthropy can invest in expanding and rigorously evaluating family-centered treatment models and their impact on child welfare systems.
The Family First Act remains a critically important policy tool. But prevention cannot succeed if it begins only at the child welfare threshold. When families become involved with the child welfare system because effective substance use treatment was out of reach, our policy choices are already limited.
The child welfare community has both the standing and the responsibility to insist on substance use treatment systems that support recovery and family stability before separation ever becomes an option.
