Children Affected by Parental Substance Use

Pediatricians positioned to break multigenerational cycle of addiction

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BOSTON – Children whose parents or caregivers misuse alcohol or use, produce or distribute drugs face an increased risk of medical and behavioral problems. According to a new clinical report by experts at Beth Israel Deaconess Medical Center (BIDMC) and Boston Children’s Hospital, pediatricians are in a unique position to assess risk and intervene to protect children. The report, “Families Affected by Parental Substance Use,” is available online today and slated for publication in the August print edition of

Pediatrics, the journal of the American Association of Pediatrics.

“Alcohol misuse and substance use are exceedingly common in this country, and parents’ or caregivers’ substance use may affect their ability to consistently prioritize their children’s basic physical and emotional needs and provide a safe, nurturing environment,” says co-author Vincent C. Smith, MD, MPH, a neonatologist at BIDMC and Assistant Professor of Pediatrics at Harvard Medical School (HMS). “Because these children are at risk of suffering physical or emotional harm, pediatricians need to know how to assess a child’s risk and to support the family to get the help they need.”

An estimated one in five U.S. children grows up in a home in which someone misuses alcohol or has a substance use disorder, the authors write. Whether from the toxic effects of exposure to these substances or from the neglect of their basic needs by parents or caretakers struggling with substance use disorders, children in these households commonly experience developmental and educational delays and, later, are at higher risk for mental health and behavioral problems. They also are more likely than their peers to have substance use disorders themselves later in life.

In their report, Smith and co-author Celeste R. Wilson, MD, Medical Director of the Child Protection Program at Boston Children’s Hospital and Assistant Professor of Pediatrics at HMS, review the clinical signs of fetal exposure to alcohol, cannabis, stimulants and opioids. Pediatricians must be increasingly on the lookout for signs of neonatal abstinence syndrome (NAS), the irritability, muscle stiffness, diarrhea – even seizures – that can result from prenatal opioid exposure. Recent research indicates that 22,000 U.S. babies were diagnosed in 2012 with NAS, the authors write, adding that more than a quarter of expectant mothers were prescribed opioid pain relievers during their pregnancy, according to a separate study.

Citing studies that say children whose parents use drugs and misuse alcohol are three times more likely to be physically, sexually or emotionally abused and four times more likely to be neglected than their peers, the authors urge all pediatricians to include questions about caregivers’ substance use as part of the routine family assessment. Some warning signs of abuse and neglect include: frequent injuries and bruises, especially in clusters or in patterns that could indicate contact with a hand, belt or other instrument; children who are withdrawn, fearful or flinch at sudden movements; a lack dental care or immunization; or ill-fitting, filthy or inappropriate clothing.

“Because pediatricians are the health care providers most likely to encounter families with young children who may be affected by substance use, they have the opportunity to help break multigenerational cycles of abuse,” the authors write. “By being informed about the effects of parental drug use on children, they can intervene when necessary.”

The authors provide sample scripts to help clinicians begin a potentially uncomfortable conversation, noting that research suggests parents who screen positive for substance use are open to pediatricians presenting them with follow-up options such as community treatment programs. In the wake of these conversations, caregivers who don’t opt for treatment may still achieve some reduction in harm by decreasing or altering their substance use, even if they don’t completely abstain, Smith and Wilson noted.

“Pediatricians who identify substance use problems in a family are not expected to solve, manage or treat these issues; rather, they can partner with other professionals to provide families access to resources,” write Smith and Wilson. “By screening, pediatricians have the opportunity to make a significant difference in the lives of the entire family affected by substance use.”