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Supporting Parents in Treatment for Opioid Use Disorder: Lessons Learned from Developmental Science on Parenting and Adolescence

Supporting Parents in Treatment for Opioid Use Disorder: Lessons Learned from Developmental Science on Parenting and Adolescence

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Authors: Estelle Berger is a PhD student at the Developmental Social Neuroscience Lab at the University of Oregon (UO). Camille Cioffi, PhD, is a Research assistant professor at the Prevention Science Institute at UO. Leslie Leve, PhD, is the Lorry Lokey Chair in Education, Head of the Department of Counseling Psychology and Human Services in the College of Education, and Scientist at the Prevention Science Institute, all at UO. These insights are from their recent working paper, Supporting parents in recovery from opioid use disorder: Lessons learned from developmental science on parenting and adolescence.

Introduction

Rates of opioid use disorder (OUD) have continuously increased over the past decade, and more than half a million people with OUD are parents living with children. However, there is limited research on how to support parents in treatment for OUD, especially for those who are parenting adolescents.

To fill this gap, we were motivated to focus attention on how to support parents in treatment for OUD who are parenting adolescents, with the goal of alleviating parental concerns about the potential for intergenerational transmission of substance use disorders. We bring together what we know from research on adolescent development, parenting, and intergenerational transmission of substance use disorders to provide recommendations that support youth and their parents in treatment for OUD.

Parenting Adolescents in the Context of Opioid Use Disorder

Adolescents are hard-wired to establish a sense of autonomy, clarify personal identity, build peer and intimate relationships, and cultivate meaning and purpose. Adolescence can also be a time of heightened risk-taking, in which teens might engage in healthy risks like adopting a new hobby or joining an unfamiliar club, or venture toward more health-threatening risks. When a parent is in treatment for OUD, these defining elements of adolescence can be both strengths and vulnerabilities; youth might pivot toward or away from maladaptive behaviors, such as substance use, depending on the caregiving environment and other contextual factors.

The children of parents with OUD are at risk of developing OUD themselves. This “intergenerational transmission” becomes particularly apparent during adolescence when young people have more opportunities to try substances. They are also sensitive to social norms, and parents who use substances might normalize or provide opportunities for teens to use substances themselves. However, we wish to underscore that intergenerational transmission of OUD is not an inevitability.

When a parent is engaged in treatment for OUD, parent-child dynamics take on additional complexity. For example, with swings in mood that often accompany substance use, parents might engage in particularly harsh parenting, which can lead to aggression, substance use behaviors, and similarly harsh parenting style in future generations. While engaged in treatment, parents might struggle to provide consistent warmth and may be over-reactive. These parental behavior patterns may make youth more vulnerable to behavior problems, depression, and challenges in school. Some adolescents who have parents with substance use disorders also experience “parentification” (i.e., parenting their parent) as they provide physical and emotional care to their parent(s). While these attributes and parent-child dynamics are not solely a result of substance use, they point to a potential vulnerability within this parenting population.

Importantly, researchers have identified four factors that can protect adolescents from developing OUD:

  1. parental monitoring,
  2. parent-child relationship quality,
  3. parental support, and
  4. parental involvement.

In general, a consistent and nurturing parent-child relationship can help youth establish independence and a stronger sense of self. However, tensions with parents emerge during adolescence as youth seek more autonomy and peer connections yet still require monitoring, help with managing conflicts, and open communication with their parents. Conflict is a healthy part of a parent-adolescent relationship when there is safe space for a wide range of emotions and flexibility–like being able to laugh with each other after a difficult conversation or argument–can create generative opportunities for adolescents to express and regulate their emotions. A positive parent-adolescent relationship is a balance of autonomy, harmony, and conflict. Parents in treatment may need additional support in achieving this balance, but in doing so they might disrupt established cycles of detrimental conflict and foster new and more supportive relationships.

Recommendations

When thinking about how best to support adolescents and their parents, we need to pay attention to context. OUD does not occur in isolation. For example, parents who are in treatment for OUD often struggle with mental health issues, depend on other substances, have limited parenting support from partners, and experience a lack of resources in their communities (Cioffi et al., 2019; Peisch et al., 2018; Dawe et al., 2003). Additionally, OUD can occur in the context of persistent racism, policing, and cultural stigma. For the parent, the child, and the family as a whole, all of these factors impact and inform opportunities for intervention to provide a robust system of community support. At each level there are opportunities to create a dynamic system which engages the parent with OUD and their adolescent to intervene on problematic parenting behaviors that predict risk and nurture existing parenting strengths that offset that risk.

In Table 1, we provide recommendations to help guide adolescents, their parents, treatment providers, policymakers, and educators. In general, we provide resources to help adolescents build self-advocacy and communication skills, and identify ways that parents can shift behavior patterns when engaging with their children. We also emphasize how practitioners can facilitate a more family-centered approach to treatment, point schools toward establishing SUD/OUD prevention programs, and urge policymakers to fund those programs. By creating supportive systems that help heal the parent-adolescent relationship, we can work towards reducing the prevalence of intergenerational transmission of substance use including OUD.

Conclusion

Adolescents are important players in their own development; this age is a period of opportunity when young people are strengthening their sense of agency and beginning to make decisions that will affect their adult lives. Even in the midst of challenges, adolescents can experience positive development when systems and communities work together to support parents in recovery. By investing in parents, we are simultaneously investing in adolescents and nurturing the future opportunities that they seek to create.

​Recommendations for supporting adolescents when a parent is engaged in treatment for OUD

​From Berger, E. L., Barrett, A.-M., Mendes, S., Leve, L. D., Pfeifer, J. H., & Cioffi, C. (2022) Supporting parents in recovery from opioid use disorder: Lessons learned from developmental science on parenting and adolescence. Working paper.

​Adolescents

  • Practice compassion with yourself and your parent: The Seven Cs
  • Identify ways to set healthy boundaries with your parent through support groups like Alateen and Narateen
  • Understand more about addiction and substance use: Just Five, Tips for Teens, and It Feels So Bad
  • Explore information about how opioids and other substances affect the brain: National Institute on Drug Abuse–Mind Matters
  • Role play and practice how to avoid or leave a context where you may be peer pressured to use substances
  • Seek Naloxone training. NARCAN is available at the pharmacy counter in all 50 states
  • Find support for loss and bereavement in instances where you may not be able to have a relationship with your parent

​Parents

  • Regain adolescent’s trust – reduce/eliminate own substance use
  • Build healthy communication patterns – provide emotional support, effective problem-solving, maintain parent-child boundaries, and monitor adolescent’s behavior while honoring the adolescent’s increasing autonomy
  • Facilitate open conversations about substance use – highlight risks, share reflections on substance use, and communicate strategies that have helped to avoid substances
  • Engage in active, shared activities like going to the movies, getting outside, or playing games
  • Seek out peer support specialists and other providers

​Treatment Providers & Other Mental Health Professionals

  • Attend to parents’ needs both for substance treatment and support for parenting an adolescent
  • Involve the family in treatment and facilitate opportunities to repair the parent-child relationship
  • Collaborate with adolescents’ schools to provide additional support when parents are engaged in treatment – create an environment in which the adolescent can share openly without worry about child welfare involvement or stigmatization from peers

​Schools

  • Integrate primary prevention programs for OUD and SUD in curriculum
  • Identify and serve students whose parents are engaged in treatment using a screening, brief intervention, and referral to treatment (SBIRT) model
  • Create a strong sense of community within the school to provide an additional resource for students to turn to when parents are engaged in treatment

​Policymakers

  • Provide funding for primary, secondary, and tertiary prevention programs in schools and communities
  • Generate and disseminate harm reduction information for adolescents and families
  • Implement medication take-back programs to remove opioids and other unneeded prescription medications from homes

Additional Resources

The Connecting Adolescent Brain

Fact Sheet

This fact sheet gives an overview of adolescent brain development and explains how access to resources, opportunities, and meaningful relationships during adolescence can build connections within our brains and with the world around us that support us into adulthood.

Brain development during adolescence is fundamentally a story of connections.

Around age 9 or 10, hormonal changes kick off a period of intense learning and development, when brain cells form, strengthen, and streamline connections in response to our experiences more rapidly than in any period of life after early childhood.

Activity increases especially in the brain networks that propel us to explore the world, learn from our mistakes, and connect with others in new ways. In turn, these new experiences prompt our brain cells to connect with other neurons in ways that help us adapt to new events and new information. These neural connections become stronger the more we use them, while unused connections are pruned away, helping the brain become more efficient at acquiring and mastering new skills and new ways of thinking.

This brain-building learning happens through direct experiences in our environments and interactive, responsive relationships—with our families and peers, in our classrooms and neighborhoods, in community activities, and even online. The resources, opportunities, and experiences we as adults provide in and out of school can help young people’s brains build the extensive networks of connections that will manage the complex knowledge and behaviors needed to navigate adulthood.

Learning by Exploring the World Around Us

One of the networks that changes significantly with the increase in hormones and dopamine at the beginning of puberty is the “reward system” in our brain. Heightened activity in this system increases the feeling of reward we get from exploring the world, taking risks, and learning from the results.

Meanwhile, the network of brain regions that make up the “social brain” also changes during adolescence. These changes help us tune into social and emotional cues, like facial expressions or social rejection and approval, and increase our desire to earn respect and contribute to others. It also enables us to learn the nuances of changing social contexts in ways that help prepare us for adult relationships.

The prefrontal cortex (the region of the brain that orchestrates critical thinking and behavioral control) undergoes its most rapid period of development during adolescence. It builds on many other systems within the brain to manage our responses to the flood of new information and intensifying emotions. Engaging with other people and our environment and learning from our successes and our mistakes, known as “action-based learning,” helps shape the prefrontal cortex by strengthening the connections within it and between it and other brain networks. We learn through repeated practice—which includes trying and sometimes failing—what is adaptive and appropriate in different situations and how to guide our behavior accordingly, in ways that equip us to pursue new forward-looking goals.

When adults provide youth with opportunities to try new things, to practice navigating emotions, and to learn from failures along the way, it helps build the brain connections that we all need to grow into healthy, thriving adults.

Policies, Experiences, and Mindsets Shape the Connecting Brain

Although we can continue to learn new skills and behaviors as adults, the adaptability of the brain during adolescence means that these connections are much more likely to form quickly in response to experiences. The extent of these changes make the adolescent years a critical window when investments in the right policies and programs for youth can shape long-term positive development.

Likewise, this makes the adolescent years a time when negative experiences including racism, other forms of discrimination, poverty, or abuse can create steeper hills for young people to climb toward a healthy adulthood. When adults ensure that all young people, especially those who have experienced earlier adversity, have what they need along their journey, they can build the skills and capacities they need to thrive as adults. This includes opportunities to explore and take healthy risks, to connect with and contribute to those around us, to make decisions and learn from the outcomes, to develop a healthy sense of identity, and to rely on support from parents or other caring adults.

Understanding how and why the brain develops during adolescence lets us provide the support young people need to build healthy connections—in their world and within their brains—that will help our youth and our communities thrive.

A Developmental Path to Policy and Programs

Science Spotlight | Education | Mental Health | Foster Care | Adversity, Bias, & Discrimination | Juvenile Justice

This spotlight offers examples of policies and programs that take a research-informed, developmental approach to supporting adolescents.

Adolescence is a time of remarkable opportunity, both for young people, who are learning and growing rapidly during these years, and for our broader society as we choose how to support young people on their path to adulthood. By aligning policies and programs with insights from developmental science, policymakers and youth-serving organizations can find ways to more effectively meet the distinct needs of adolescents and support youth to become healthy, thriving adults who can contribute to their families, communities, and the wider world.

In the last several decades, research on adolescent development has dramatically increased our understanding of how young people ages 10 to 25 develop psychologically, emotionally, and physically. Scientists with research expertise in neuroscience, psychology, biological sciences, sociology, education, and public health, among other disciplines, have contributed to our understanding of the core developmental needs of young people. Researchers, often in partnership with young people themselves, have also investigated how these needs might be met in settings that shape adolescents’ lives, such as school, home, the workplace, faith-based communities, and out-of-school activities. As a result of this work, we know more today than ever before about the types of experiences and relationships young people require during adolescence to advance toward healthy adulthood.

Understanding the developmental science of adolescence can help generate new ways of thinking about the challenges and opportunities our youth face and ultimately advance science-inspired solutions, systems, and support.

We offer below a few examples of policies and programs that draw inspiration from a developmental approach toward adolescence. In addition, the appendix included in the PDF highlights external clearinghouses that collect and assess evidence on existing programs and practices relevant to adolescents, which may be useful as you consider how to identify and support the core developmental needs of adolescents in your policy or program.

Young adult courts​

Research suggests that young people ages 18 to 25 who have committed moderate criminal offenses experience worse life outcomes and higher rates of recidivism when they are formally processed in the criminal justice system–that is, when they proceed through a standard series of court appearances and resultant sanctions, such as time in detention. This suggests a misalignment between the treatment of these young people in the adult criminal system and their developmental needs and capacities as adolescents.

One approach that several jurisdictions in the United States have implemented in response to the needs of older adolescents is to establish “young adult courts.” For example, in partnership with developmental scientists from the University of California, Irvine, the Orange County Superior Court in California launched a pilot Young Adult Court in 2018. Young men ages 18 to 25 who proceed through the Young Adult Court receive intensive case management, supervision from officials who have received training regarding adolescent development and behavior, and resources to “strengthen their health and wellness, life skills and employment, housing, and education.”

Upon completion of a minimum 18-month, court-supervised program, a judge may dismiss or reduce a young person’s felony charge. Structured as a randomized controlled trial, the Young Adult Court in Orange County will allow researchers at the University of California, Irvine to investigate the relationship between participation in this court and young people’s short- and long-term outcomes across several areas, including health, behavior, education, and career.

​Later school start times

In 2019, California passed legislation requiring non-rural middle and high schools to begin the school day no earlier than 8:00 and 8:30 a.m., respectively. During the legislative process, the bill’s author noted that this shift aligns with research about the importance of sleep during adolescence. Indeed, studies have shown that later school start times make a difference for young people. In 2016, the Seattle School District shifted its school start times from 7:50 to 8:45 a.m., and a before-and-after study found that rather than simply staying up later, students slept an average of 30+ minutes more at night. Other research links later school start times to improved moods, better class attendance, and fewer car crashes among 17- and 18-year-old drivers.

​Extended foster care eligibility

The earliest design of the child welfare system in the United States responded to the needs of physically abused infants and toddlers and prioritized protection and caregiver permanency for young children. As a system, it was not aligned with the unique developmental needs of adolescents, who can increasingly exert agency in their own lives as they practice reasoned decision-making and who may look to a variety of supportive adults and peers to help build resilience and a positive sense of identity.

One notable example of adapting this youth-serving system to better align with our understanding of adolescent development is the series of major federal policy reforms in the last 25 years that noted and aimed to address the needs of older adolescents with foster care experience and paved the way for state-level action. In general, these reforms have expanded the opportunities for young people beyond the age of 18 to receive services and establish or deepen connections with supportive adults.

Today, in approximately 48 states, the District of Columbia, and American Samoa, young people may elect to remain in extended foster care past the age of 18 and receive supportive resources. Although extended foster care services vary by jurisdiction, they might include a range of resources that align with the capacities and needs of older adolescents as they learn to navigate life choices related to healthcare, housing, education, and employment with appropriate support from caring adults.

​Treatment Foster Care Oregon

The Treatment Foster Care Oregon program is a research-informed alternative to placing youth with severe emotional or behavioral disorders in residential group care settings. First developed in 1983, Treatment Foster Care Oregon today offers separate programs for (defined by TFCO as 7 to 11, which encompasses early adolescence) and adolescence (defined by TFCO as 12 to 17) that prioritize family settings and effective parenting over approximately nine months.

The program involves weekly meetings for foster parents that teach positive parenting strategies, crisis support and respite care for foster parents, one-to-one mentorship for youth with a young adult to promote social skill building, and family and individual therapy for caregivers and youth. The program’s design explicitly takes into account the unique developmental needs of middle childhood and adolescence. In fact, the program’s effectiveness seems to be related to the support it provides for some important developmental needs of the adolescent years, including by tapping into youths’ need to find a respected place among peers and to maintain secure relationships with supportive adults.

In randomized control trials, this program has been shown to cut in half the arrest rate of both boys and girls. In addition, girls in the Treatment Foster Care Program experienced half the rate of depressive symptoms, a third less drug use in their early to mid-20s, and about half as many teen pregnancies.

​Strong African American Families Program

Strong African American Families (SAAF) is a family-centered program for rural, Black families designed to strengthen early adolescents’ relationships with their caregivers and prevent unhealthy risk taking. The University of Georgia’s Center for Family Research created the program expressly to apply key research insights about healthy adolescent development, including the importance of developing a positive sense of self and racial identity as well as maintaining relationships with supportive adults.

While participating in SAAF, youth ages 10 to 14 and their caregivers attend weekly program sessions over a seven-week period. Through interactive games, discussions, and role playing activities, youth work through topics such as setting goals, developing their sense of identity, understanding their values, and handling peer pressure. Parents complete separate sessions focused on developing communication skills and discussing ways to support their children’s development. Adolescents and their parents also attend joint sessions focused on working together, staying connected, and supporting youths’ goals.

The program reduced risky sexual behavior, substance use, and behavioral problems, and increased positive racial identity. In addition, a recent analysis suggests that SAAF participation may reduce negative mental health effects in adolescents caused by experiencing racial discrimination.

​Partnering with young people to design California HOPE accounts

Young people have the ability to make well-reasoned decisions about their well-being when given the time and information to consider their options. Including young people in the design of policies and programs that impact their lives can benefit both adolescents and their communities.

The approach taken by the California HOPE for Children Trust Account Program (the “HOPE Program”) is one example of intentionally engaging young people in the earliest stages of policy development. In 2022, the California legislature created the HOPE Program to provide financial trust accounts for youth from low-income families who lost a parent or guardian due to COVID-19 and young people who have spent at least 18 months in the foster care system. The legislature required a Board to oversee the program, advised by a working group of subject matter experts. These groups recognized “that the HOPE program could not be designed without significant direction from a set of youth who were most likely to be beneficiaries of the program.”

As a result, the groups sought assistance to assemble a Youth Panel of Experts. These 12 young people ages 15 to 21 had experiences that mirrored the qualifying criteria for a HOPE account and were compensated for their participation in the HOPE Program’s design. The HOPE Program’s 2024 report to the state legislature outlines an implementation plan for the program and other critical administrative choices that reflect the contributions and collaboration of the Youth Panel of Experts. The report also outlines an ongoing role for the Youth Panel of Experts, who will provide insights into future public outreach and educational materials for young people eligible for the program and their families.

When Adolescents Contribute to Others it Supports their Well-Being and Their Communities

Fact sheet | Education | Community Engagement | Out-of-School Time

This fact sheet explains how opportunities to contribute to others can build our autonomy, agency, and identity and can support our sense of purpose during adolescence.

Adolescence is a time of remarkable opportunity and growth. In the years between ages 10 and 25, changes in our brains and social environments increase both our ability to contribute to others and the positive feelings we get from kind and helpful behaviors toward others.

When policies and programs support adolescents to find ways to contribute and cultivate their sense of purpose, it leads to healthier, more connected communities.

Adolescence is an important time for contributing to others. During the developmental period between childhood and adulthood, we forge our sense of who we are and how we want to contribute to the world. Throughout our adolescent years, our physical, cognitive, and emotional capabilities mature in ways that allow us to contribute to our friends, family, schools, and broader community in deeper, more meaningful ways than when we were younger.

Opportunities to not only contribute, but to reflect on the meaning of our contributions and to have our contributions recognized, build our autonomy, agency, and identity and can support our sense of purpose—the forward-looking feeling that our lives are directed and significant. All of these are important to positive development during adolescence, helping us navigate adversity and achieve goals throughout adulthood.

Research on adolescent development helps explain how opportunities to contribute to others support well-being.

Brain development during adolescence supports our ability and motivation to contribute to others. The network of areas in our brain that activates in social interactions matures rapidly during our adolescent years, deepening our understanding of the complex feelings, perspectives, and needs of other people. We become better able to determine who needs our help and what kind of help they might need. In addition, brain regions associated with our sensitivity to rewards become more reactive during and after puberty, increasing the positive feelings we get from novel experiences as well as kind and helpful behaviors, such as contributing to others. Connections between these regions also improve during adolescence.

Our social environments—including families and peers—can motivate us to contribute to others. Socially, we become more motivated to find a valued place and role among our peers. Contributing is one way to feel valued: studies have shown that students who are helpful, cooperative, and sharing tend to be more appreciated and liked than those who use fear or intimidation to gain status. Young people from families and communities where contributing is a particular value seem to feel more of a sense of reward when helping.,

The right support can help young people who have been marginalized. Being marginalized as a result of race, ethnicity, gender, sexual orientation, or religion can also motivate adolescents toward a sense of purpose to help others in their families, schools, or communities through activism or civic engagement. Family engagement, adult role models, connections through religious or other community groups, and support to process our experiences can all help young people cultivate a positive sense of purpose.

Contributing to others provides adolescents the experiences they need to succeed as adults. Supporting friends and family builds the intimacy we need to form positive, long-lasting relationships in adulthood. Seeing that our actions can have a positive effect on the world can help us build a sense of autonomy, agency, and identity. Contributing to others also supports a sense of meaning and purpose, which are associated with greater emotional well-being, academic success, and resilience, all of which can be powerful assets as we navigate adversity and achieve goals throughout adulthood.

The opportunity to reflect on the experience of volunteering might be essential to ensuring positive developmental impacts from the activity. Reflecting on service we perform during our adolescent years—which can take place through journaling, art, essay writing, or group discussion—can help us consider the broader impacts of our contribution and attach meaning to the experience.

​​➢ Provide opportunities for young people to make meaningful contributions to their social groups and communities. Programs that support youth to contribute can have positive effects on their mental and physical health, support their academic success, and give them opportunities to explore ways they can be a force for good in our society, now and in the future.

➢ Policies and programs should address inequities in adolescents’ opportunities to make meaningful contributions in their everyday lives by ensuring that all young people have a range of options to contribute and to have their contributions recognized.

➢ Families are typically the first context where youth can contribute to others through common household chores such as cooking or taking care of siblings. Youth from many lower-income, ethnic-minority, and immigrant families play significant instrumental roles in their families, and the value of these contributions and the skills they require should be recognized by colleges and employers.

➢ While helping family is a type of contribution that can benefit youth, time-intensive caregiving can sometimes be a source of stress that negatively impacts mental health. Schools can support caregiving youth by offering flexibility in course schedules, awarding community service hours for their caregiving, and educating teachers and counselors about the experience of these youth. Learn more about how to support caregiving youth here.

➢ Involving middle and high school students in decision making around classroom and school policies like seating arrangements, learning activities, or grading practices has been shown to increase students’ motivation and connection to the school community.

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