A Three Generation Approach to the Opioid Epidemic

Every 15 minutes a baby is born in the U.S. with symptoms of opioid withdrawal (view full report here). These newborns are often irritable, difficult to soothe, to settle down to sleep and to feed. These predictable challenges can be draining for already exhausted parents and undermine their sense of effectiveness and competence. Newborns’ withdrawal symptoms may interfere with their earliest contributions to the attachment process, just as a mother’s struggle with substance use may complicate hers.

Research on the long-term effects of exposure to opioids during pregnancy suggests long-term developmental impacts, but it is fraught with the confounding factors associated with substance use disorder (SUD), especially other poverty-related adversities, and trauma, which affects half or more of women of childbearing age with SUD. The research is, however, clear that the single most important way to mitigate the effects of in utero exposure on children’s development is the quality of the primary caregiving relationship.

Yet many children are placed in foster care by state child protective service agencies, even though foster care systems in many communities are too overwhelmed to provide the kind of quality caregiving that these infants need. Whenever possible, strengthening families — including grandparents who step in to help — and the quality of these caregiving relationships is the best hope for children’s recovery, and for parents’. Tragically, many parents who lose custody of a child exposed in utero to substances will deal with this loss by continuing to use substances and go on to bear more children who are exposed.

Stigma often prevents these adults from recognizing that they deserve and need help. It also often infiltrates health and mental health professional attitudes toward them, further alienating families from otherwise effective treatments. Parents and expecting parents are often subject to particularly harsh judgment as healthcare providers struggle to deal with their frustration about treating newborns whose distress could have been prevented. Yet the perinatal period and the first years of life offer uniquely powerful opportunities for prevention, healing and recovery. Expectant and new parents may find powerful new motivation to seek treatment for their new baby’s sake, even when they don’t feel that they themselves deserve it. These Touchpoints in a family’s development are times of heightened vulnerability and opportunity when we can touch into the family system to bring hope for families so that they can dare to hope for themselves.

The Brazelton Touchpoints Center’s (BTC) work on prenatal exposure to substances can be traced back to the use of Dr. Brazelton’s Neonatal Behavioral Assessment Scale to detect behavioral effects at birth of in utero exposure to medications, illicit substances, and environmental toxins. In 2007, BTC began partnering with HRSA/MCHB-funded First 5 Santa Clara County grant to use the Touchpoints Approach to create a shared vision and common language for 28 agencies across the county, including the courts, that served families in which an infant had been born exposed in utero to methamphetamine. Since then, BTC has continued to expand its activities in this area in many ways, including a congressional briefing on Capitol Hill on the opioid epidemic, hospital grand rounds and other presentations around the country on a whole-family approach to opioid use disorder, consultations to Tribal communities on preventing and treating SUD, and adapted Touchpoints and Newborn Behavioral Observations system (NBO) trainings.

Through programs and tools like the Touchpoints professional development series and the NBO, BTC and the Brazelton Institute are helping families and children overcome the opioid epidemic and helping family-facing professionals battle stigma. These providers learn to explore together with parents each individual newborn’s competencies. Practitioners and parents learn together to help infants born exposed in utero to thrive by cultivating strong parent-child attachments, and building parental confidence as well as motivation for their own recovery process. Family-facing practitioners learn together with peer-recovery coaches who have lived experience of SUD and substance exposures for their own children. This silo-busting approach tackles the implicit biases that can undermine professionals’ relationships with families and children, and, as a result, the effectiveness of the treatments they provide.

Just one result of these joint trainings is a mindset shift toward deeper understanding of SUD as a disease process — opioids can rewire the brain — and greater empathy for parents living with SUD. Evidence of this mindset shift within the Touchpoints and NBO professional development training and reflective practice activities abounds. Take, for example, the peer-recovery coach who appreciated what she learned about newborns experiencing effects of exposure but did not think that the direct hands-on use of the NBO would be a natural part of her work with parents in recovery. Yet, when a new father expressed to her concerns about what to do if his baby cried during an upcoming supervised visitation, she was ready to offer what she’d learned in the NBO training about the challenges with soothing that babies with exposures face, and the strategies for overcoming them. The father later recounted that he did not only successfully soothe his baby with the specific technique taught to him by his recovery coach; he also showed the other fathers in the visitation group how to soothe and console their babies as well.

We can support the attachment process when parent and infant are both struggling with challenges of self-regulation. We can boost parental self-confidence and self-efficacy and help family-facing professionals recover their own sense of effectiveness and overcome the frustration that leads to blame and reinforces stigma. To do so, we need strengths-based approaches like the Touchpoints Approach and the NBO that focus not only on the baby or the adult in recovery, but also on parent-infant-provider relationships, building skills for understanding infant behavior as communication, and for self-reflection, so that providers can surface and move beyond bias, and so that parents can dare to believe in themselves and to have hope for their family’s future.