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Impact of Substance Abuse and Neonatal Abstinence Syndrome on Tribal Communities

As more research has been conducted on the short- and long-term effects of opioid addiction, one group is particularly impacted by substance abuse: infants and children of those who use opioids. Infants who are exposed to opioids in the womb are often diagnosed with Neonatal Abstinence Syndrome (NAS). Opioid addiction rates are rising among women and mothers, and American Indian and Alaska Native populations have the highest rates of addiction. Their children are the most at-risk for NAS. Since NAS can present in children in a wide variety of ways, it’s important that early interventions and educational services take place in child care settings, in addition to homes. Child care providers and early educators need to be aware of the impacts of opioid addition on children in order to better serve families. Child care providers who serve American Indian and Alaska Native populations need to be acutely aware of this, as native populations have the highest rates of addition.

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Tribal Communities Are Most Affected by Substance Use Disorders

According to the National Survey on Drug Use and Health, 10.2% of AI/AN adults have a substance use disorder, which is higher than the U.S. total population of 7.4% of people who reported substance abuse disorder within the past year. In 2018 an astonishing 28.5% of Native Americans reported drug abuse within the past year, compared to the national population at 19.4% drug abuse within the past year.

Some tribes have taken the initiative and conducted research within their own populations to track the changes in opioid use and addiction. With financial support from the CDC and the National Institute of Health, the Northwest Portland Area Indian Health Board published findings on the rates of NAS throughout Oregon. The study found that between 2010 and 2017, the rate of being diagnosed with NAS was 1.6 times higher for American Indian and Alaska Native infants than Non-Hispanic White infants. Not only did the study find a discrepancy of NAS rates by race, but it also found an increase in the overall rate of NAS diagnoses. In 2010, the rate of AI/AN newborns diagnosed with NAS was 6.7 per 1,000 live births. By 2017, that rate had increased by 153%, with 17.0 per 1,000 live births of AI/AN newborns diagnosed with NAS.

The Blackfeet Reservation of Montana has seen particularly alarming rates of substance abuse in recent years. A study conducted by the Blackfeet Tribal Health Department found that 44% of pregnant women who were tested for illicit substances tested positive for opioid use, with 32% of infants delivered in the Blackfeet Community Hospital showing signs of NAS during their stay. The tribe also found that 35% of women tested for illicit substances at delivery tested positive for methamphetamine. Substance abuse was identified by the Blackfeet community as the biggest problem on the reservation.

Children Born with NAS May Have Higher Rates of Educational Disabilities

A 2018 study conducted in Tennessee found that children with NAS were significantly more likely to be referred for a disability evaluation, with 19.3% of NAS children referred and 13.7% non-NAS children referred. The NAS children who were assessed were also more likely to meet the criteria for a disability, with 15.6% of assessed NAS children meeting criteria and 11.7% assessed non-NAS children meeting the criteria. This study specifically looked at children diagnosed with developmental delay or speech and language impairment or who were receiving classroom support or speech therapy. As high rates of opioid use continue, it is important to note the best use of child care and classroom needs for children with NAS.

The U.S. National Library of Medicine National Institutes of Health published a similar study concluding that children who suffered from NAS had slower rates of mental and academic development than the average child. Comparing children of the same age, socioeconomic status, and gender on their performances on literacy and numeracy tests, the study found that third graders with NAS scored lower than their peers. They also found that seventh grade students with NAS on average scored lower than the non-NAS fifth grade level. The study did recognize that environmental factors may be another indicator of how these children perform in school and on academic exams such as the ones they were given.

The two above studies are the first of their kind; before these were conducted, we had little to no knowledge of the long-term effects of opioid exposure or NAS. While these studies provide some evidence, there is still much more research that needs to be done to understand how early interventions, like therapy or educational services, can be effective in child care and home settings.

Tribes Respond

Programs have been created to help tribes meet the needs of both mothers and children who suffer from substance abuse and NAS. For example, an analysis of five different tribes in Minnesota using the Substance Exposed Infants In-Depth Technical Assistance program cited some of the greatest barriers for American Indian women. Minnesota has seen increased rates of treatment admission for heroin and prescription opioids. They cited that many women who use drugs during pregnancy fear that they will be placed in custody or have their children taken from them, are not educated on the proper steps for prenatal care, or face transportation and child care issues that prevent themselves from seeking care. For initial NAS care, the program recommended that hospitals promote maternal-infant bonding and more training for both staff and parents/caregivers related to NAS infant care. Later care recommendations include more knowledge about the use of traditional medicines to treat behavioral issues seen in young children with NAS and support mothers who do not want to place their child on medication. These initiatives use developmental tools in tribal early childhood care programs to better understand the impacts perinatal substance exposure has on child development.

Other major findings from the Substance Exposed Infants Initiative found that hospital protocols can be inconsistent across the country and within states, which limits access to services for treating infants. There are also challenges to collecting and reporting data, which may be why we are seeing much more recent research on the subject. Some of the ways in which states and tribes are pushing for change include developing statewide hospital protocols to promote consistent identification of infants in need of services and creating a guide for consistent and non-stigmatizing language to be used when referring to pregnant women and mothers with substance use disorders and their children.


NAS has intense, negative short-term and long-term impacts on children making it more difficult for children to develop a healthy foundation upon which to learn and grow and impacting their school readiness. Additional research should be conducted to inform effective early interventions and to showcase any existing programs that already work on this issue. In order to provide the best care possible, child care providers and early educators should be educated on this research and prepared to address the symptoms of children in their care. As tribes receive new funding through the pandemic relief bills, they should use this money to make sure kids get screened and are supported if diagnosed. It is critical tribes invest in addressing both NAS and drug addiction due to the lasting effects on children and families, and the child care providers serving them.

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