Kate’s fourth child was the one she never talked about. She and her boyfriend were living on the street in a town outside of Cincinnati, shooting heroin daily. “We never felt my belly. We didn’t talk about what he would look like or what we would name him,” Kate recalls, “It’s not that it wasn’t there but we just knew that this baby was not going to be ours.”

Child services had taken Kate’s three children from her to live with her mother. Though she had been abusing drugs off and on since her oldest child, now 11, was an infant, it took the state five years to terminate her custody. During that time, Kate was abusing Subutex and heroin, shoplifting and stealing checks from other people’s homes. The question one might ask after talking to Kate is: What took the authorities so long?

Melinda Gushwa of the Simmons College School of Social Work worries about the answer to that question. Her analysis of child fatalities shows that child-welfare workers are not paying enough attention to parental substance abuse. “The number one reason kids die is because of neglect. It’s because the parents are impaired and not providing adequate supervision.” Looking at the case notes after a fatality, Gushwa says, she always sees some variation of “child was happy, healthy and well cared for.” But the caseworker is not asking questions about the parents’ drug use, or when they last met with a counselor or went to a meeting. And the agencies that are supposed to be providing treatment do little follow-up. “My research has shown most CPS (child protective services) workers say a death wasn’t preventable,” explains Gushwa. “But when you go back, you can see all these red flags.”

Child-maltreatment fatalities have risen significantly in the United States, from 1,589 to 1,700 between 2016 and 2017 alone, according to a recent report from the Department of Health and Human Services. Between one-third and two-thirds of substantiated child-abuse reports involve parental substance abuse. So why aren’t caseworkers asking more questions—or the right questions—in cases like Kate’s? And why aren’t they removing children from these homes much earlier?

For some observers, the answer is simple: Kate is white. As a recent article in The Atlantic noted, “Today’s opioid epidemic presents a mostly-white face to the world, and the larger ‘epidemic of despair’ tends to target communities in vaunted ‘Middle America,’ as opposed to inner-city Baltimore and Detroit. . . . Instead of wide-scale carceral panics and schemes to imprison addicted mothers, the country has considered a public-health approach.” It’s true that child-welfare officials’ response to the opioid epidemic has differed from how they reacted to the crack epidemic, as reflected in the numbers of kids in foster care. That total reached 567,000 in 1990, during the crack scourge. And while it has climbed significantly during the opioid crisis, it is still only at 437,000 (even as the population of children under 18 rose by 15 percent between 1990 and 2017).

But the disparity in reaction may have less to do with race than with a desire not to repeat what is broadly seen as an overreaction to the crack crisis. Martha Grace, retired chief justice of the Massachusetts Trial Court’s Juvenile Department, remembers that “there was supposed to be a nexus between crack cocaine babies and ‘super-predators.’” The implication was that social workers should remove these children from their homes before they could become part of a growing wave of violent crime. Some crack-addicted mothers did indeed give birth to babies with severe neurological and organ damage. Such examples were sensationalized in the press, but by the 1990s, researchers became aware of the difficulties in interpreting the effects of crack on fetal development. Multiple factors affected the fetuses and young children of women who used crack, including consumption of alcohol and cigarettes, poor prenatal care, and inadequate nutrition. Isolating these effects from the influence of cocaine was impossible among the relatively small groups of women examined, who self-reported their own drug usage, offering low confidence of accuracy.

Almost all reports were retrospective, meaning that only the worst cases came to attention; many “crack babies” were developmentally normal, though they were born already in withdrawal from the drug. Ideally, researchers would have data on a group of pregnant women followed over several months. In a now-classic 1992 article in the Journal of the American Medical Association, Yale child psychiatrist Linda Mayes outlined a larger array of interpretive complexities and concluded that there was “an apparent rush to judgment about the extent and permanency of specific effects of intrauterine cocaine exposure on newborns.” All of these factors have influenced the way that social workers today approach families with substance-abuse issues.

But have we taken the lessons of the crack epidemic too far in assuming that kids can stay in homes with parents who abuse drugs? It’s helpful to remember that many children of crack-addicted parents experienced direct abuse. Douglas Besharov, the first director of the U.S. National Center on Child Abuse and Neglect, says that “there was a consensus that crack made many users more violent.” Besharov, who also served on the child-fatality review board in New York City during the epidemic, adds that the drug “created really violent nasty behavior” among many parents. “In hindsight,” Besharov says, “it’s easy to say it wasn’t that bad. There’s a lot of reinventing history.”

Gushwa notes that the long-term prospects for children in homes where their primary caretaker is abusing drugs or has a history of doing so should make caseworkers pause more often. “What the research shows on substance use is that [addiction treatment] often doesn’t take the first second or third time. It takes a lot of time to remain sober. And it’s impossible for many to retain sobriety.” While drug use may not be “prima facie evidence of child neglect,” says Besharov, “it’s not neutral information.” Even if babies born exposed to drugs in utero do not have physical birth defects, they are still being sent home with parents who may not be capable of caring for them. These children are not getting the kind of nurturing love essential to proper social and intellectual development. Even worse, their parents may not be paying attention to their safety and well-being. In our quest to make up for past mistakes, we can’t ignore these facts.

Photo by Spencer Platt/Getty Images


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