Children and Families

Screen for Adverse Childhood Experiences (ACEs)

Use Clinical Screening Tools in Pediatric and Primary Care

Implement Student Assistance Programs

Expand Community Prevention Coalitions


Screen for Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences (ACEs) is the term used to describe traumatic or stressful events experienced by persons under the age of 18.1

ACEs scores can range from 0 to 10 and children with higher scores are more likely to develop health conditions and substance use disorder (SUD) in their lifetime. In the United States, 61% of adults have experienced at least one form of a traumatic event in their lives, and 1 in 6 have experienced four or more.1

ACEs have a significant impact on individuals, and the consequences can affect entire communities, making it a serious public health issue. Many events that cause ACEs include parental SUD, childhood abuse or neglect, sexual abuse, and other forms of violence, which can have a lasting effect on behavior and health.2 If left unaddressed, these ACEs can increase the likelihood of individuals developing mental illnesses, SUDs, and other mental and physical health conditions that affect the overall quality of life.3

ACEs can be categorized into three types:

  • Childhood abuse (e.g., physical, emotional, or sexual abuse);
  • Neglect (e.g., physical or emotional neglect; and
  • Household dysfunction (e.g., SUD or mental illness in the household, parental separation or divorce, domestic violence, and parental incarceration).

ACEs are preventable and should never go unaddressed. One of the key communities impacted by ACEs is children with parental SUD. Evidence-based strategies, such as screenings, early intervention, and prevention programming, remain underutilized. Preventing the development of SUDs must be a priority and can change the trajectory of the crisis. Programs that provide interventions that are culturally responsive and resilience-focused to children impacted by addiction and that have ACEs are a key strategy in disrupting intergenerational SUDs and providing targeted services to arguably one of the most at-risk populations of children.

The Research

  • Preventing ACEs can lead to a significant reduction in chronic health conditions and socioeconomic challenges, including obesity (by 2%), depressive disorder (by 44%), substance use (by 33%), medically uninsured people (by 4%), and unemployment (by 15%).4
  • Research shows that for each one-point increase in the ACE scale, the odds of children developing a SUD in adulthood rises by 34-41%.5
  • Studies have shown that screening early can increase the identification of ACEs and can improve child outcomes and parent-child relationships when professionals utilize interventions to address ACEs, such as parenting education, referrals to services, counseling, and social supports, in primary care settings.6,7
  • ACEs can have significant implications on society. Unaddressed ACEs cost hundreds of billions of dollars every year. Researchers estimate a 10% reduction in ACEs could save $56 billion annually.1

Program Spotlight

Adverse Childhood Experiences Response Team (ACERT)

Manchester Police Department, mental health providers, head start, early parent education, and child welfare partner in ACERT.

ACERT consists of a plain-clothes detective from the police department, a crisis services advocate that specializes in domestic violence, and a family advocate who is stationed at the police department and connects clients to health services. The team interacts with individuals as soon as crime scenes are secured.

The team offers a release form to families, which provides for a warm handoff to social service agencies and allows for the agencies to call the family directly. The form provides a built-in resource for parents who may not know where to turn to help their children. Parents receive assurance that the release is one way and has no impact on legal proceedings or law enforcement involvement. As of June 2019, ACERT has been deployed over 250 times, contacting more than 1,400 children and referring 1,014 children to medical and public health services.8


Screening for Substance Use Disorders in Pediatric and Primary Care

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice for identifying, reducing, and preventing risky substance use and misuse, as well as dependence on alcohol and drugs.

The first component of SBIRT is screening, where a healthcare professional assesses a patient for risky substance use using standardized screening tools. If a patient screens positive for risky use or potential SUD, a healthcare professional engages the patient in a short conversation, providing feedback and advice. The healthcare professional may make a referral to treatment for patients at higher risk who express interest in receiving specialty SUD services.9

SBIRT can be implemented in primary care and other healthcare settings and enables healthcare professionals to systematically screen and assist people who may not be seeking help for a substance use problem but whose drinking or drug use may cause or complicate their ability to successfully handle health, work, or family issues. SBIRT aims to prevent the unhealthy consequences of alcohol and drug use among those whose use may not have reached the diagnostic level of a SUD.

Reduction in drug use over a 6-month period among SBIRT patients.

The Research

  • Findings from a 2019 study suggest that adolescents that received SBIRT in primary care settings reported few psychiatry visits and were less likely to have mental health diagnoses or chronic conditions after a 1 year follow-up compared to the control group.10 At year 3 of the study, those in the SBIRT group reported less outpatient visits, fewer SUD diagnoses, and more visits to substance use treatment.
  • A study published in Drug and Alcohol Dependence reviewed the effects of SBIRT services on 459,599 patients screened at various medical settings over a 6 month period and found a 68% reduction in drug use over a 6-month period among SBIRT patients.11 Of those who reported problematic drinking at baseline, the rate of heavy alcohol use was 39% lower at the 6-month follow-up. Those who received brief interventions or referrals to specialty treatment also reported improved overall health, fewer arrests, more stable housing, and improved employment outcomes.

Program Spotlight

Screen and Intervene: NH Youth S·BI·RT Initiative

In response to the escalating rates of substance use and overdose across the state, the New Hampshire Charitable Foundation partnered with the Conrad N. Hilton Foundation to launch the Screen and Intervene: NH Youth S·BI·RT Initiative in 2014 to expand SBIRT practices for adolescents in primary care settings; screen no less than 10,000 youth and young adults (ages 12-22) by 2017; and measure and address policy and financial barriers.

The Initiative uses an action learning collaborative approach to educate healthcare providers about medical service integration, substance use screening among youth, electronic medical records workflows and data collection, and supporting cultural competence. The initiative also promoted inter- and cross-site collaboration for improving sustainability and process improvements. By 2018, the Initiative screened 15,126 youth and provided training to nearly 600 providers and other ancillary staff.16


Student Assistance Programs in Each Middle and High School

It is critical to intervene early when a person is using substances to ensure that risky use does not progress into a SUD, especially among adolescents and young adults who have a heightened vulnerability to developing a SUD due to their developing brains.

Comprehensive school/community-based assessment and early intervention activities and programs, such as Student Assistance Programs (SAP) in middle and high school settings, have shown to be effective in stopping the cycle of addiction before the disorder becomes more complex and difficult to treat. SAPs are designed to promote positive social, emotional, and behavioral functioning and prevent and reduce substance use among school-aged youth. A successful SAP provides a full range of services, including prevention, education, awareness, individual assessments, skill-building and copy strategies, and specialized counseling groups. SAPs should offer universal, selective, and indicated prevention strategies, filling a gap identified by many school administrators and parents.

The Research

  • Research shows that SAPs are associated with improved school attendance, assignment completion, and student behavior; higher rates of academic achievement and high school graduation; increased self-control, self-efficacy, and social competence; and decreased substance use and problematic behaviors.17
  • A three-year retrospective study of middle and high school students that participated in a student assistance program in Pennsylvania found that two-thirds of the SAP-referred students improved or stabilized their attendance by two-thirds, 60% reported no further disciplinary suspensions, and 68% graduated from high school.18

Program Spotlight

Project SUCCESS (Schools Using Coordinated Community Efforts to Strengthen Students)

Project SUCCESS (Schools Using Coordinated Community Efforts to Strengthen Students) is a school-based model to prevent and reduce substance use among adolescents. The program places trained counselors in public and alternative high schools to provide a full range of services, including prevention education, awareness, individual assessments, and specialized counseling groups.

Project SUCCESS works with high-risk students attending traditional secondary schools and alternative schools. The program begins with an eight-session Prevention Education Series during which students participate in sessions such as Being an Adolescent; Alcohol, Tobacco, and Other Drugs; Relationships with Family and Friends; and Skills for Coping. Over the course of the psycho-education program, students develop a relationship with the trained counselor. In public schools, the series is conducted in the 7th and 9th grade health education curricula. In alternative schools, the series is implemented in accordance with the unique structure of each institution.

Upon completing the education series, students who are identified by the Project SUCCESS counselor as being at high-risk for developing a SUD are assessed and work with the counselor to devise a course of action that best suits their needs. Students who are identified as high-risk are often using substances, have parents, siblings, or friends who use substances, have experienced transitions, and/or have positive attitudes toward substance misuse. These students are assigned to a group focused on either prevention or intervention based on their level of SUD, exposure, and overall motivation.


Expand Community Prevention Coalitions

Community coalitions are an effective approach that brings together the key sectors within a community (e.g., public health, social services, government, treatment and recovery services, education, first responders, patients, and families) to collaborate, develop, and implement comprehensive strategies that reduce risk factors for substance use and addiction, such as high rates of poverty, social norms, and drug availability, and counterbalance them with protective factors, such as community engagement and healthy activities.19,20

saved for every dollar invested in prevention programs

Community coalitions serve to establish and strengthen communities while improving health outcomes and promoting attachment and engagement amongst its members and reducing the likelihood of substance use and that young people will live lives free of addiction.21,22

Coalitions utilize the Strategic Prevention Framework, a community‐based, public health approach to reduce alcohol, tobacco and other drug use that includes providing information, enhancing skills, providing support, enhancing access and reducing barriers, changing consequences, changing physical design, and modifying or changing policies.

The Research

  • A national evaluation of community coalitions conducted in 2019 found that substance use/misuse declined for youth living in communities with a coalition and community coalitions significantly increased the number of youth who reported not using substances in the past 30 days.23
  • Research shows that every dollar invested in prevention programs, it can save more than $64.20

Program Spotlight

Jackson County Anti-Drug Coalition (JCADC)

In 2009, twelve community organizations partnered with the local health department in West Virginia to form the Jackson County Anti-Drug Coalition (JCADC) in reaction to a series of drug and alcohol-related deaths among local youth.

The coalition has since grown into a county-wide effort to reduce drug experimenting, drug use, and underage drinking among youth and, over time, to reduce substance misuse among adults in communities throughout Jackson County and surrounding areas in West Virginia. Members include law enforcement, youth coalitions, treatment providers, medical professionals, civic and religious groups, community members, business owners, the board of education, and local media.


Expand Support for Mothers with Opioid Use Disorder

Prenatal exposure to certain substances, including alcohol and opioids, can cause adverse health outcomes such as poor fetal growth, premature birth, birth defects, stillbirth, and neonatal abstinence syndrome (NAS).24

SUD presents substantial risks during and after pregnancy and, if left untreated, pregnant women are up to six times more likely to have maternal complications.25 Between 2010 and 2017, the number of women with an opioid use disorder (OUD) increased by 131%.24


Increased Patient Outcomes

Newborns born with NAS, a group of conditions that is caused when newborns experience withdrawal, are more likely to have longer hospital stays and be re-hospitalized within 30 days after birth, and cost hospitals an additional $449.1 million a year.24,26

There is also a lack of prenatal care services and policies to support pregnant and postpartum women (PPW) who are justice-involved.27 Over half of all women in U.S. prisons and 80% in jails are mothers.28 Approximately 58,000 pregnant women are incarcerated every year, and an estimated 14% of pregnant women admitted to jail, and 26% to prison, have opioid use disorder.29,30 The overwhelming majority of children born to incarcerated mothers are separated from them immediately after birth and placed with relatives or into foster care. This separation disrupts opportunities for mothers and children to develop emotional bonds, with the likely result that the children will have emotional and behavioral problems.32

It is critical to diagnose and treat maternal SUD to provide the family unit with the best possible foundation for treatment, recovery, and stability. For PPW who are diagnosed with opioid use disorder, it is essential to provide rapid referrals to evidence-based treatments, such as medications for opioid use disorder (MOUD). It is also critical to provide comprehensive support services and training programs to help mothers tackle and cope with parenting challenges while in treatment and to offer children the healthiest possible foundations while preventing them from adverse risks associated with parental SUD.

The Research

  • Both methadone and buprenorphine, two MOUDs, are recommended for treating OUD during pregnancy and improving outcomes for women and their newborns.25
  • Research shows that longer duration of MOUD during pregnancy can decrease the risk of preterm birth and lower birth weight.33
  • MOUD, in combination with behavioral therapies, has shown to reduce opioid use, prevent withdrawal symptoms, decrease the risk of overdose, and is associated with overall improved maternal and infant outcomes.34

Program Spotlight

Moms and Babies Program, Decatur Correctional Center, Illinois

The Moms and Babies program is a partnership between the Illinois Department of Corrections, the WestCare Foundation and additional community-based partners who work together to provide both in-prison and community- based services for mothers and their babies. Post-release community reentry services are integral to the program. Following release from prison, providers ensure participants receive ongoing case management, home visits, and linkages to services in the community. Using a combination of pre-release services and post-release case management, the program builds solid foundations for strong family structures to continue upon release. Women who participate in prison nursery programs show lower rates of recidivism, and their children show no adverse effects as a result of their participation.35


Implement Programs for Children Impacted by Parental Substance Use Disorders

8.7 million United States children under the age of 17 years old live in a home with at least one parent who has a SUD.36

These children are at an increased risk of depression, anxiety, difficulties with academic and social functioning, suicide attempts, committing crime, and substance use behaviors.37,38 Children living with family members who have a SUD are four times more likely to develop a SUD themselves.39 As a result, many children who have a family member with an active SUD live in kinship or foster care.40,41


reduction in substance use

Addiction prevention and mentoring programs for youth ages 9-17 address the needs of these children by providing them with the tools they need to take care of themselves and cope with their family circumstances and break the intergenerational cycle of addiction. It is essential to ensure that parents struggling with addiction who have preventative cases or whose children have been removed to out-of-home placement have access to evidence-based addiction treatment.

The Research

  • Evidence-based mentoring programs, such as Big Brothers Big Sisters, have been shown to improve relationships and grades in school, reduce violence, and prevent alcohol and drug use among high-risk children.42
  • A cohort study of 11,960 students that participated in a family-focused intervention in 6th grade and a school-based intervention in 7th grade found a 31% reduction in substance use after 6.5 years and was particularly impactful among high-risk youth.43
  • School-based programs that focus on health promotion and school connectedness have shown to increase school attendance and academic achievement and decrease substance use, emotional problems, and violence.44

Program Spotlight

Breed All Stars Program

In 2015, opioid use and overdose death in Lynn, Massachusetts was increasing drastically, especially among Breed Middle School students. Community leaders grew concerned and recognized the need to intervene with students early.

In response, the school superintendent, in collaboration with the Essex County District Attorney’s Office, the Lynn Police Department, and Project COPE, developed the Breed All Stars program to support children impacted by parental SUD and who are at risk of adverse childhood experiences (ACEs). The program is designed to reduce violence and bullying, delay sexual activity, and prevent substance use while creating positive relationships between students and teachers. One of the program’s major goals is to provide enough protective factors to outweigh risk factors, increasing each student’s opportunity to embark on a healthy and successful future.


Implement Child Welfare Interventions

The number of children in the foster care system has risen steadily over the years, in large part due to the opioid epidemic.45

Many children in the child welfare system have a family member with an active SUD or have lost parents to an overdose and are currently living in kinship care. In 2019, over 39% of the children who were placed in the child welfare system were removed due to parental SUDs, a 20% increase since 2000.46 These children are at an increased risk for depression, suicide, poverty, delinquency, anxiety, hom­­­­elessness, and SUDs.


more likely to complete treatment than traditional proceedings

Relatives who step in to care for these children require a variety of supports, including mental health services for themselves and their families, kinship navigators, respite care, and financial assistance. Parents, youth, and kinship caregivers report tremendous value in prevention and treatment services to help promote recovery and strengthen the family.

Child welfare agencies and other children’s services organizations can take steps to improve their response to addiction including: training staff on SUDs, expanding access to evidence-based interventions and family-based SUD treatment in child welfare agencies, and providing necessary support services for caregivers. Family-based treatment provides wraparound support such as childcare, tutoring, parenting classes, housing support, job training, and individualized treatment. This effective and holistic treatment model provides both adults and children the services and support they need to succeed and stay together as a family.47 Recent advances have been made to develop programs that promote cross-sector collaboration between child welfare, substance use treatment, and the justice system to support family reunification including home visitations programs, and family treatment courts.

The Research

  • Research shows that home visitation programs, such as the Nurse-Family Partnership (NFP) program, reduce reports of child abuse and neglect by 48% and reduce other related risk factors such as parental substance use and child behavioral problems.48 The program also reduces the use of welfare and criminal behavior among women and substance use and arrests among the children who participated in NFP.
  • Parents that participate in Family Drug Treatment Courts have shown to be 25-35% more likely to complete treatment compared to traditional proceedings and 15-40% more likely to be reunified with their children.49

Program Spotlight

Sobriety Treatment and Recovery Teams (START), Kentucky Cabinet for Health and Family Services

START is a specialized child welfare service delivery model for children and families impacted by parental substance use and child maltreatment. START helps parents access SUD treatment and keeps children in-home placement when it is possible and safe. The program uses an integrated service delivery model that promotes cross-system collaboration between child welfare agencies, SUD treatment providers, the justice system, and other family-based providers to ensure timely access to evidence-based services.

START’s integrated intervention pairs a social worker with a family mentor (peer support employees in long-term recovery) to work collaboratively with a small number of families to provide peer support, intensive treatment, and child welfare services. The program’s goals are to: keep children safe, reduce child placement in state custody and achieve child in-home permanency, improve parents’ ability to care for children, achieve parental sobriety, expand quality and access to treatment and support services for families with parental substance use, and improve cross-system collaboration and service delivery.

Mothers who participated in START achieved sobriety and early recovery at nearly twice the rate of mothers treated without START (66% vs. 37%).50 Children in families served by START were 50% less likely to be placed in state custody as compared with children in a matched control group (21% vs. 42%)