Potential Emerging Risks Among Children Following Parental Opioid-Related Overdose Death | Pediatrics | JAMA Pediatrics | JAMA Network
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Figure.  Mental Health and Human Services Encounters Following Parental Overdose Death
Mental Health and Human Services Encounters Following Parental Overdose Death
Table.  Eligible Cohort Observed Over the 5-Year Period
Eligible Cohort Observed Over the 5-Year Period
1.
Felitti  VJ, Anda  RF, Nordenberg  D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.   Am J Prev Med. 1998;14(4):245-258. doi:10.1016/S0749-3797(98)00017-8PubMedGoogle ScholarCrossref
2.
Pham  S, Porta  G, Biernesser  C,  et al.  The burden of bereavement: early-onset depression and impairment in youths bereaved by sudden parental death in a 7-year prospective study.   Am J Psychiatry. 2018;175(9):887-896. doi:10.1176/appi.ajp.2018.17070792PubMedGoogle ScholarCrossref
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    Research Letter
    April 13, 2020

    Potential Emerging Risks Among Children Following Parental Opioid-Related Overdose Death

    Author Affiliations
    • 1Allegheny County Department of Human Services, Pittsburgh, Pennsylvania
    • 2Allegheny County Health Department, Pittsburgh, Pennsylvania
    • 3Allegheny County Office of the Medical Examiner, Pittsburgh, Pennsylvania
    JAMA Pediatr. 2020;174(5):503-504. doi:10.1001/jamapediatrics.2020.0613

    The incidence of unexpected deaths from opioid overdoses sharply increased in Allegheny County, Pennsylvania, in recent years. In 2017 alone, the county’s opioid-related overdose rate was 51.5 per 100 000, more than triple the US rate (14.9 per 100 000). This represented more than 90% of all unintentional overdoses.

    The opioid epidemic is also affecting families and, most importantly, children. People who died of an overdose were most frequently between age 25 to 54 years and in their child-rearing years. Substance use in the household is considered an adverse childhood experience and is associated with health risks and disease in adulthood.1 A recent longitudinal study found that bereavement by sudden parental death was associated with an increased incidence of depression, primarily during the first 2 years, along with posttraumatic stress disorder and functional impairment.2 Yet, little is known about the number of children who experienced these losses.

    The goal of this study was to determine the number of children who experienced unexpected parental loss because of opioid-related overdoses in Allegheny County. It also sought to understand their human service encounters and mental health services use subsequent to parental loss.

    Methods

    Using integrated public system data that existed within the county’s data warehouse, we identified a cohort of individuals who had died of an unintentional drug overdose between July 2002 and December 2017 who were also listed as a parent on a birth certificate between January 1999 and December 2017. The result was a cohort of children and adolescents born in Allegheny County who were 18 years or younger during this period and who may have been affected by an unexpected death of a parent.

    We then summarized their involvement with human services and other public systems in the months and years following the parent’s death (when appropriate and age-eligible) and presented cumulative percentages (Table). This study was conducted by the department using information that already existed in the department as records of operations from the delivery of heath and human services. It was conducted for planning purposes and to improve the quality of services the department delivers to county residents and qualified as exempt research.

    Results

    There were 664 individuals listed as parents on the birth certificates (392 [59%] were fathers) of 1008 children (989 [98%] were younger than 18 years): 252 (25%) were younger than 5 years, 373 (37%) were between age 5 to 9 years, 262 (26%) were age 10 to 14 years, and 131 (13%) were age 15 to 18 years. Within 3 months following the parent’s death, nearly 1 in 10 of the Medicaid-enrolled children had used mental health services (11.1%). Within 5 years, this had increased to nearly 1 in 4 children (24.8%) (Figure).

    At the time of the parent’s death, nearly 1 in 10 children was involved in child welfare (10.6%). Within 5 years, this had increased to nearly 1 in 5 children (19.8%). Within this time, 8.5% of the children had experienced out-of-home placement.

    Dependency-related court involvement increased from 7.2% at the time of parent’s death to 11.3%. Delinquency-related court involvement remained relatively low throughout the 5-year period.

    Discussion

    Over a 16-year period, more than 1000 children lost a parent because of an unintentional drug overdose. These children experienced elevated risks for mental disorders, as observed by increased mental health service use in the years following parental death. This finding is consistent with a prior longitudinal study. Increased involvement in child welfare and out-of-home placement seems to reinforce our understanding of the potential for drug use interfering with child safety and parental care.

    This study provides evidence of the challenges and emerging health risks experienced by children as a result of the opioid overdose epidemic. It is likely an underestimate given our methods, the aging of the cohort over time, and the variations in family composition. Public discourse regarding clinical approaches and policies to address the effect of unexpected loss among children is warranted, as it is an underrecognized dimension of the country’s opioid epidemic.

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    Article Information

    Corresponding Author: Eric G. Hulsey, DrPH, MA, 737 S Braddock Ave, Pittsburgh, PA 15221 (eric.hulsey@gmail.com).

    Published Online: April 13, 2020. doi:10.1001/jamapediatrics.2020.0613

    Author Contributions: Dr Hulsey had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Hulsey, Hacker, Collins, Dalton.

    Acquisition, analysis, or interpretation of data: Hulsey, Li, Williams, Collins, Dalton.

    Drafting of the manuscript: Hulsey, Li.

    Critical revision of the manuscript for important intellectual content: Hulsey, Hacker, Williams, Collins, Dalton.

    Statistical analysis: Hulsey, Li, Dalton.

    Administrative, technical, or material support: Hulsey, Hacker, Williams, Dalton.

    Supervision: Hulsey, Collins, Dalton.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Felitti  VJ, Anda  RF, Nordenberg  D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.   Am J Prev Med. 1998;14(4):245-258. doi:10.1016/S0749-3797(98)00017-8PubMedGoogle ScholarCrossref
    2.
    Pham  S, Porta  G, Biernesser  C,  et al.  The burden of bereavement: early-onset depression and impairment in youths bereaved by sudden parental death in a 7-year prospective study.   Am J Psychiatry. 2018;175(9):887-896. doi:10.1176/appi.ajp.2018.17070792PubMedGoogle ScholarCrossref
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