CCDF Policy Opportunities for Supporting Populations Impacted by Opioid Misuse and Substance Use Disorders

To

State, Territorial and Tribal Lead Agencies administering child care programs under the Child Care and Development Block Grant (CCDBG) Act as amended, and other interested parties

Subject

Child Care and Development Fund (CCDF) Policy Opportunities for Supporting Populations Impacted by Opioid Misuse and Substance Use Disorders

References

The CCDBG Act (42 U.S.C. 9857 et seq.); section 418 of the Social Security Act (42 U.S.C. 618); 45 CFR Parts 98 and 99

Purpose

To assist CCDF Lead Agencies supporting the economic stability of families by enhancing access to child care and early learning services to support the development of vulnerable children, particularly in communities impacted by opioid misuse and substance use disorders.

Background

The Office of Child Care supports low-income working families by improving access to affordable, high-quality early care and afterschool programs. OCC administers the Child Care and Development Fund (CCDF) — a block grant to state, territory, and tribal governments that provides support for children and their families with paying for child care that will fit their needs and that will prepare children to succeed in school.

CCDF also improves the quality of care to promote children’s healthy development and learning by supporting child care licensing, quality improvements systems to help programs meet higher standards, and training and education for child care workers. We at OCC establish and oversee the implementation of child care policies, and provide guidance and technical assistance to states, territories and tribes as they administer CCDF programs.

As a block grant, CCDF is designed to give Lead Agencies the flexibility to develop policies that meet the needs of their families. Depending on the State, Territory, or Tribe’s funding and policy priorities, this flexibility should allow Lead Agencies to adapt to new vulnerabilities that are impacting their communities, such as the dramatic increase in opioid misuse and substance use disorders.

Drug overdose deaths and opioid-involved deaths continue to increase in the United States. According to the Centers for Disease Control, the majority of drug overdose deaths (66%) involve an opioid. In 2016, the number of overdose deaths involving opioids (including prescription opioids ^[1] and heroin ^[2]) was 5 times higher than in 1999. From 2000 to 2016, more than 600,000 people died from drug overdoses. On average, 115 Americans die every day from an opioid overdose. Parental substance use can have devastating impacts on children. Research has generally found that substance use can contribute to parenting challenges, and is linked to child maltreatment. A recent study by HHS found that increases in drug overdose deaths and drug-related hospitalizations corresponds with substantial increases in reports of child maltreatment and foster care caseloads. Children of parents misusing substances are also at higher risk of facing physical and behavioral health issues, which can further impede the development of healthy parent-child relationships.^[3]

Substance misuse also has consequences for economic stability. Unemployment is a significant risk factor for substance use. In turn, substance use, including alcohol, increases the likelihood of unemployment and decreases the chance of finding and maintaining a job. The use of FDA-approved medications through medication-assisted treatment (MAT), in conjunction with counseling and behavioral therapies, and access to a range of services and supports—including work, housing, and child care support—assists parents in recovery, stability, and wellness.^[4] In addition, research demonstrates that women are more likely to stay in treatment longer if they are able to maintain their caregiving roles while engaged in treatment and recovery support.^[5]

Guidance

When considering how to assist communities that have been impacted by substance misuse, the CCDF program can play a vital role. By providing assistance to families working toward recovery, child care can provide a stabilizing force for families in a precarious situation.

CCDF Lead Agencies determine their policies within federal parameters, which are established primarily by the Child Care and Development Block Grant Act and CCDF regulations. Lead Agencies have flexibility in policy areas that include establishing specific eligibility criteria (including income thresholds and eligible activities), co-payment policies, and how to invest in quality activities.

With that flexibility in mind, below are some policy areas that CCDF Lead Agencies may consider when examining their programs:

Eligibility

Substance use disorder impacts many families across the country and access to child care subsidies can be an important stabilizing force for families. Access to child care can support parents in treatment while also giving children access to child care services.

We recognize that States must weigh how to best use and prioritize available resources when determining whether to serve parents in substance use treatment. If the Lead Agency wants to enhance CCDF eligibility options for families addressing opioid misuse or substance use disorder, some eligibility policy options to consider are:

• Including Substance Use Treatment as an Eligible Activity: In order to be eligible for CCDF, families must be working or attending job training or an educational program. However, CCDF Lead Agencies have flexibility in defining “job training or education program” and can include time spent in treatment for substance abuse in their definition. Leveraging this flexibility would allow families to place their children into safe and affordable child care while entering into a treatment regimen, often a critical step toward stable employment and one that often requires a significant commitment of their time away from caring for their children.
• Protective Services Eligibility: Lead Agencies have the flexibility to include families in a substance use treatment program in the Lead Agency’s definition of “in need of protective services” or as a vulnerable population. In States, Territories, or Tribal areas where the prevalence of substance misuse is particularly high, this option would allow the Lead Agency to not apply certain eligibility criteria and waive co-payment requirements for such families.

Important Considerations: When designing policies that increase access to child care services for families impacted by substance use, the CCDF Lead Agency should take into account:

• the State’s definition of child abuse and neglect as it relates to parental substance use; and
• the mandatory reporting responsibilities of each individual in the child care system (e.g. providers, directors, CCDF eligibility workers)

It is critical to consider these two factors to ensure that Lead Agency policies do not have unintended consequences for families that are seeking assistance. If Lead Agencies are considering substance use treatment as an eligibility criteria, they should have a clear understanding of what, if any, admission of substance use would constitute abuse and neglect. Any mandatory reporters should have a clear understanding of what they are required to report and equally important, what does not require a report. If the Lead Agency chooses to design such policies, the Lead Agency should work with their Child Welfare agency and other relevant entities to ensure a comprehensive understanding of the policy’s impact.

Coordination

CCDF requires States to coordinate the provision of services with other agencies, including (but not limited to) those responsible for public health, employment services/workforce development, TANF, Medicaid and State children’s health insurance programs, and child care resource and referral agencies. OCC recommends that such collaboration include coordinated efforts for how agencies can address opioid misuse and substance use disorders, such as including CCDF subsidies as one element of a “plan for safe care” for substance-exposed infants, safety plans for children at risk of foster care placement, and reunification plans for children in families where parental substance use was a reason for removal.

Consumer Education

CCDF requires comprehensive consumer education efforts, which can be used to provide families with vital information on misuse of opioids, alcohol and other substances. Consumer education could include dissemination of information about:

• Other programs for which families that receive CCDF assistance may be eligible, including possible access to treatment options through federal resources such as the SAMSHA Behavioral Health Treatment Locator ^[6] and access to treatment through the State Behavioral Health or Medicaid agencies;
• Evolving research and best practices concerning children’s development, meaningful parent and family engagement, physical health and development, substance use disorder (including for pregnant and postpartum women, and the immediate and long-term health needs of infants with Neonatal Abstinence Syndrome), and state policies regarding social-emotional behavioral health of children.

Training

CCDF requires that all caregivers, teachers, and providers serving CCDF children receive training in essential health and safety topics, including “recognition and reporting of child abuse and neglect,” “child development,” and “any other subject area determined by the Lead Agency to be necessary to promote child development or to protect children’s health and safety.” These topics align well with efforts to help providers best serve the needs of the children in their care who may be impacted by substance use. Lead Agencies should consider examining their training and professional development systems to incorporate training on substance use disorder and opioid misuse, recognition of use and referral processes to appropriate addiction services and counseling.

Neonatal Abstinence Syndrome: Lead Agencies should consider whether their Health and Safety trainings should include Neonatal Abstinence Syndrome (NAS), which is a condition that happens when an infant goes through withdrawal from substance exposure after birth. Training providers to recognize the signs and symptoms of NAS may help them better care for the child’s particular needs. However, the research around NAS continues to evolve, so if Lead Agencies incorporate this topic, they should ensure that trainings and materials reflect the most current research.

Grants and Contracts

While CCDF subsidies primarily come in the form of vouchers and certificates, Lead Agencies can also establish grants and contracts with local organizations to establish child care slots for eligible children. A Lead Agency could use this mechanism to partner directly with a child care program affiliated with a treatment facility to establish subsidized child care slots for families enrolled in treatment for substance use disorder to increase support for these vulnerable families. This would ensure that a certain number of slots are available for impacted communities and facilitate the urgent needs of families entering treatment.

Quality Funds

States are required to expend a percentage of their funds on activities to improve the quality of child care (“quality dollars”). Activities that may assist families impacted by opioids and substance misuse that may also align with allowable quality activities, include (but are not limited to):

• Providing training and outreach on engaging parents and families in culturally and linguistically appropriate ways to expand their knowledge, skills, and capacity to become meaningful partners in supporting their children’s positive development;
• Including effective, age-appropriate behavior management activities, including positive behavior interventions and support models for birth to school-age, that promote positive social and emotional development and reduce challenging behaviors;
• Supporting Lead Agency or local efforts to develop or adopt high-quality program standards relating to health, mental health, nutrition, physical activity, and physical development;
• Carrying out other activities, including implementing consumer education provisions determined by the Lead Agency to improve the quality of child care services provided, and for which measurement of outcomes relating to improvement of provider preparedness, child safety, child well-being, or entry to kindergarten is possible.

Provided activities fit within the approved categories as described in the CCDF regulations (at 45 CFR 98.53), such as family engagement and professional development, States may spend quality dollars on activities to address the opioid epidemic.

Increased Funding Levels

The Consolidated Appropriations Act of 2018 included a $2.37 billion increase in CCDF Discretionary funds over the FY 2017 appropriations levels. This increase was maintained in FY 2019. This dramatic increase presents Lead Agencies with a unique opportunity to re-examine how they can allocate resources to serve families impacted by opioids and substance misuse.

Resources

Below are some resources on substance misuse and outreach that may be helpful in supporting families and communities dealing with such issues.

• Substance Misuse (Head Start): https://eclkc.ohs.acf.hhs.gov/mental-health/article/substance-use-disorder-recovery
• SAMHSA’s Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants: https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregn...
• HealthReach’s low-literacy patient materials about opioids, opioid addiction, and opioid treatment (includes documents, videos, and audio), available at https://medlineplus.gov/languages/opioidsandopioidusedisorderoud.html  
• National Center on Substance Abuse and Child Welfare’s Infants with Prenatal Substance Exposure, available at https://ncsacw.samhsa.gov/resources/substance-exposed-infants.aspx
• National Center on Substance Abuse and Child Welfare’s Neonatal Abstinence Syndrome, available at https://ncsacw.samhsa.gov/resources/opioid-use-disorders-and-medication-assisted-treatment/neonatal-abstinence-syndrome.aspx
• Substance abuse and Mental Health Services Administration (SAMHSA). (2016). A collaborative approach to the treatment of pregnant women with opioid use disorder (No. HHS Publication No. (SMA) 16-4978). Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration
• Substance Abuse and Mental Health Services’ Center for the Application of Prevention Technologies Resources to Prevent the Non-Medical Use of Prescription Drugs, Opioid Misuse, and Opioid Overdose (2018), available at https://www.edc.org/center-application-prevention-technologies-capt#key-activities
• Office of Women’s Health. (2017). Final Report: Opioid Use, Misuse, and Overdose in Women. Washington, DC: US Department of Health and Human Services. Retrieved from https://owh-wh-d9-prod.s3.amazonaws.com/s3fs-public/documents/final-report-opioid-508.pdf  (PDF) U.S. Office of Special Education’s Programs Intervention IDEAs for Infants, Toddlers, Children, and Youth Impacted by Opioids, available at https://  (PDF)osepideasthatwork.org/sites/default/files/IDEAslIssBrief-Opioids-508....  (PDF)
• Centers for Medicare & Medicaid Services (CMS). (2018, June 11) Centers for Medicare & Medicaid Services (CMS) Opioids Roadmap. Retrieved from https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemic-roadmap.pdf  (PDF)
• Center for Medicare & Medicaid Services (CMS). (2018, June). CMS Roadmap to address the opioid epidemic (infographic). Retrieved from https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/...  (PDF)
• Center for Medicare & Medicaid Services (CMS). (2018, June 11). Neonatal Abstinence Syndrome: A critical role for Medicaid in the care of infants. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/cib060818....  (PDF)

Questions

Direct inquiries to the Child Care Program Manager in the appropriate ACF Regional Office. Contact information for Regional Offices can be found here: /occ/resource/regional-child-care-program-mana....

/s/
  _________________________
Shannon Christian
Director
Office of Child Care