The opioid epidemic that is plaguing the nation is taking a heavy toll on a particularly vulnerable group: the children of those with substance use disorders. While many of these children are being sent to live with grandparents or other family members when a parent overdoses or displays other problems, a growing number are being placed in the foster-care system, which in many states is struggling to keep up with demand.

From 2013 to 2015, the number of children in foster care nationwide jumped almost 7 percent to nearly 429,000, according to the U.S. Department of Health and Human Services' Administration on Children and Families. Parental substance use was cited as a factor in about 32 percent of all foster placements, a rise of 10 percent from 2005.

The increase in demand for foster care comes at a time when opioid deaths have surged. From 2000 to 2015, more than half a million people died of an overdose, and currently 91 people a day die from overdoses of prescription or illicit opioids, according to the Centers for Disease Control and Prevention. And, unfortunately, many children, the indirect victims of the crisis, are not getting the care and services they need.

"This is a neglected subpopulation," says John Kelly, PhD, associate professor of psychiatry in addiction medicine at Harvard Medical School, and the founder and director of the Recovery Research Institute at Massachusetts General Hospital. "Because we're trying to put out the fire in terms of stopping overdose deaths, we haven't really been attending to other casualties, including kids most importantly."

To lessen the long-term effects on children, psychologists are treating children in the foster-care system in outpatient, inpatient and residential treatment programs and in school-based mental health programs.

Treating children in foster care

Richard Ruth, PhD, associate professor of clinical psychology at George Washington University, in Washington, D.C., is among psychologists who have seen a "staggering" increase in the number of foster children in the system, largely due to the opioid epidemic. In nearby Maryland, for instance, opioid deaths nearly quadrupled between 2010 and 2016, leading the governor to declare a state of emergency. Baltimore saw foster-care placements leap 30 percent from 2014 to 2017.

Ruth says he gets calls daily from people seeking help for themselves or loved ones due to opioid use. Agencies refer foster children to him for issues that include parental substance use. Some of his patients are teens who have developed substance use disorders themselves.

Ruth also has treated patients through a volunteer counseling program for children in foster care, A Home Within. This national charitable organization recruits therapists to care for one child pro bono for as long as it takes, with weekly visits that typically last about three years. This kind of high-quality, consistent care is a contrast to how foster children typically are treated, says Ruth. "Too often what happens to foster kids is that they go to underfunded, under-resourced clinics where the therapists are not well­supported," he says. "They have a new therapist every few months."

Psychologist Anthony Mannarino, PhD, who directs the Center for Traumatic Stress in Children and Adolescents at Allegheny General Hospital in Pittsburgh, has also seen an uptick in the number of children who are put into foster care due to a biological parent's opioid use disorder. The trauma they face can be highly complex. "We see kids who found their parent when they overdosed and were waiting until the paramedics came," he says. "In those cases, a parent may have died and the child is often left wondering what he or she could have done to save the parent."

The center uses Trauma­Focused Cognitive Behavioral Therapy (TF-CBT) to help these children process and recover from their traumatic experiences. TF-CBT has been used extensively to treat children in foster care, Mannarino says. The therapy involves building coping skills so children can learn to more effectively manage post-traumatic feelings and thoughts. Children also work on trauma narration and processing—sharing details about their trauma and their reactions to it. Foster parents are typically an integral part of the treatment.

"Foster children have responded very well to TF-CBT and often experience a major reduction in trauma-related symptoms and behavioral problems," Mannarino says. In one study, foster children were significantly less likely to have their foster placement disrupted because of behavioral difficulties after participating in TF-CBT (Children and Youth Services Review, Vol. 31, No. 11, 2009).

Mannarino says that his two-year follow-ups indicate the therapy is improving the mental health of these children, adding that there are a large number of TF-CBT-trained therapists who can provide this evidence-based care to foster children. But he wonders how many children who need this help haven't been identified or brought in for treatment.

Other psychologists are providing outpatient or residential services that allow children to stay with their parents during treatment, which promotes a "much healthier, positive attachment," says Hendrée Jones, PhD, executive director of the Horizons program at the University of North Carolina at Chapel Hill. Though she doesn't have extensive published data on the program's effectiveness, Jones says many of the children of opioid-using parents improve quickly with treatment—going from scared or acting out to, within 30 days, "coming up and hugging people."

New research suggests that keeping families together during treatment benefits both parent and child. A study by Natasha Slesnick, PhD, of The Ohio State University, found that when substance-using mothers and their children were treated together, both were less likely to use substances than if the mothers received individual treatment without their children's involvement. The children were also less likely to have behavioral problems, such as conduct disorders, or to experience depression and anxiety (Family Process, published online, 2017).

More outreach needed

Although there is growing awareness of the mental health challenges of these children, many still have needs that are not being addressed, says Mannarino. Often, shame and stigma keep families from seeking help.

To help find children who may have developed their own substance use disorders, Kelly recommends that practitioners screen children and adolescent patients who present with anxiety, depression or other mental health conditions. (He suggests using the ASSIST screening tool, developed by the World Health Organization.) Psychologists can also help these children by speaking to policymakers about effective practices that can make a difference in treating children affected by substance use disorders, says Jones.

"I think it's more urgent than ever that we as psychologists step up to the plate," she says. "Our voices need to be heard for solutions for the epidemic that we're facing."