When child-protective services took Heather Cantamessa’s children from her 10 years ago, she knew she needed help for her addiction to methamphetamines; she’d just been too afraid of losing her children to ask for it.

Two of her children went to their father’s sister, who was sick of addiction-related drama and cut them off from their mother. Cantamessa was allowed to see her other two kids, who went into foster care, twice a week for two hours each time. Cantamessa was relatively lucky. In some parts of the country, visits are just one hour once a week, and sometimes when parents are jailed for narcotics, children in foster care may not see their mother or father at all.

Visits were held in a small room with a police-interrogation window, behind which a visitation monitor sat scribbling notes that could later be used in court. Before they were taken, Cantamessa’s children would climb into their mother’s bed to cuddle, and Cantamessa would make cars for them out of cardboard boxes. But during visits, Cantamessa told me, “I was scared that the baby would cry, and I wouldn’t be able to calm her down.… I was scared that if I said or did the wrong thing, they’d write all that down and use it against me.”

Cantamessa’s children were confused and angry. They wanted to know why they couldn’t come home, but Cantamessa said the visitation monitor told her, “You can’t talk to them about that.”

Cantamessa said, “At the end of visits, my 2-year-old would cry and scream my name, and I would cry and get panicky. Afterward, the caseworker would tell me that if I didn’t make the good-byes better, they’d cancel my visits.”

Driven by shame and grief, Cantamessa’s addiction worsened for the three months after she lost her children. After six months, however, she found a treatment program that helped her get sober. But then her caseworker announced that visits caused Cantamessa’s daughters to “regress” and that Cantamessa would be selfish if she didn’t stop seeing them. Shocked, but also full of self-loathing and not wanting to further harm her daughters, Cantamessa agreed to stop visits. It was over a year before she was allowed to see her daughters again.

Today, Cantamessa is a parent advocate in Washington State. She’s part of a group of parent advocates and former foster youth who say that child-welfare systems show the same disregard for parent-child bonds that the government demonstrates when it separates and detains migrant kids at the US-Mexico border. The research is clear on the psychological and physical damage these practices inflict: Parent-child separations lead to increased anxiety and depression, lower IQs, and post-traumatic stress disorder in children.

At least in theory, the federal government agrees. In an interview last year in The Chronicle of Social Change, Jerry Milner, associate commissioner of the Children’s Bureau, rightly said: “We should consciously avoid inflicting psychological and emotional damage to children in our efforts to achieve physical safety” by protecting “the integrity of the parent-child relationship whenever possible.”

But in the day-to-day running of child-welfare systems, the federal government has acknowledged that little has changed for families. A March report by the Department of Health and Human Services documented a 10 percent rise in children in foster care nationally, from 397,600 in 2012 to 437,500 in 2016, with 36 states seeing a rise in the foster-care rolls during those years. One of the major drivers of the increase, according to experts, is the opioid epidemic.

That rise is particularly concerning to those who remember how foster care ballooned between 1984 and 2005, nearly doubling over two decades. During that period, children lost contact with their parents, siblings were regularly separated, and a generation of foster youth aged out of the system hurt and alone. At the time, the separations were partly based on a belief that crack-addicted parents were lost causes. But in 1998 a study from the University of Florida found that infants allowed to stay with mothers despite their cocaine use during pregnancy did better on all their developmental milestones than babies placed in foster care.

Some have thought that because the opioid epidemic is also devastating white communities, the response would be different this time, but Vivek Sankaran, a law professor at the University of Michigan, told me, “While opioids have impacted white people more than crack did, it is still poor people who are coming into the child-welfare system, so we haven’t responded quickly.”

Kodi Baugham and Nico’lee Biddle, leaders in FosterClub, a national network for youth in foster care, said it’s impossible to know whether having their children removed will be the “rock bottom” that parents need to turn around their addiction or an overwhelming pain that makes it even harder for them to recover. For Baugham’s mother, the threat of having her parental rights terminated drove her to sobriety. For Biddle, involvement with the system—and the experience of being treated like “worthless people”—deepened her parents’ addiction and ultimately hastened their drug-related deaths. But it’s the trauma of separation to children, said Baugham and Biddle, that leads FosterClub to advocate for helping families stay together whenever possible.

Focusing on six states where child-welfare placements have risen more than 50 percent—Alaska, Georgia, Minnesota, Indiana, Montana, and New Hampshire—the Department of Health and Human Services report from March criticizes the lack of effort child-welfare systems have made to keep families together and the paucity of services parents can access. “Assessment of parents’ substance use was often cursory and lagged behind placement decisions,” the report states, noting “widespread treatment shortages.”

“There may be instances where the plan is for a family member to move in to increase safety, or for a mother and child to go to inpatient treatment together. But the response I see being implemented most often in Minnesota is to remove,” said Joanna Woolman, the director of the Child Protection Program at the Mitchell Hamline School of Law. In Alaska, “Parents are put on waiting lists for months at a time” before they are accepted into drug-related services, said Elizabeth Brennan, a lawyer representing parents in Anchorage. Even then, the services are frequently inadequate. “Clients often go into a seven-day detox and then are released without any type of support. To assume they’re going to succeed is pretty absurd,” she said.

Lastly, the report focuses on bias against medication-assisted treatment (MAT), which involves administering a regulated dose of an opioid to control cravings. “Research has clearly shown that MAT is more effective than other treatment approaches…at least doubling rates of opioid abstinence,” the report states. Despite that, it continued, “Some child welfare staff and judges expressed reservations about reunifying children with parents who were stabilized on methadone or buprenorphine.”

The result in most states is a growing child-welfare system. And as more kids enter the system, the more difficult it is to ensure frequent parent-child contact, since most parents start with the requirement that visits be supervised, typically by an overburdened caseworker. In Ramsey County, where Woolman practices law, one hour a week is standard practice. “That’s the equivalent of two days a year. It’s shockingly inadequate…. And with increased caseloads, we’ve seen a marked decrease in opportunities for visitation and a huge increase in cancellations,” she said.

The impact of separations, followed by infrequent or irregular contact, has a profound effect on children, even when families eventually get back together.

Cantamessa was allowed to visit her daughters again after their caseworker discovered they were being maltreated in their foster home. That’s when the judged reconsidered the possibility of Cantamessa’s reunifying with them. Cantamessa had been drug free for over a year, and six months after restarting visits, her daughters came home. But by then, her older daughter was diagnosed with reactive-attachment disorder. It took Cantamessa a long time to remake the bond with her younger daughter, too. “She didn’t want hugs. She didn’t feel she could count on anything. She was scared to get attached, even though we’d had an attachment before she went into foster care,” Cantamessa said.

The pain of abandonment is there, too, for children who are adopted. In the 1990s, Suzanne Sellers, then addicted to crack, had her two children adopted out of foster care. When she delivered her son, she didn’t know that the hospital might test her urine for drugs without her knowledge or permission. After she tested positive, a guard stood watch with his hand on his gun while she held her son. Then she was forced to leave the hospital alone.

In many places, the laws have gotten even harsher. Earlier this year Arizona and Kentucky passed legislation that make it possible for mothers who used drugs during pregnancy to have their parental rights terminated immediately following a baby’s birth.

Sellers, today a leading voice in child-welfare reform, said “I asked time and time again, ‘Will you help me?’ But they referred me to short-term treatment that didn’t help. The only reason I knew about long-term treatment was from my friends at the crackhouse.” By the time she lost her parental rights, Sellers was sober, employed, and attending school.

But when her kids turned 18, they sought out a relationship with her. Her son even came to live with her. “They wanted to know their mother, and they wanted to hear my side of the story. But none of it has been easy. Distrust would be the number-one issue. Then there’s the lack of bonding. And then there’s the pain,” said Sellers.

“Being removed from your family impacts your life forever,” said Biddle, now a licensed clinical social worker working with children in foster care. “A lot of it isn’t, ‘Mom or Dad hurt me.’ It’s, ‘Why can’t I live with Mom or Dad?’”

In May, Phil McGraw—better known as Dr. Phil, the tough-love talk-show host—testified in Congress that when it came to child welfare, “tough love” doesn’t work. While some of his medical advice may be questionable, he used his celebrity to argue that the government should invest in treatment programs that allow parents and children to stay together, noting that when newborns experience neonatal-abstinence syndrome—similar to withdrawal in adults—hospital stays can be reduced from 22.4 days to 5.9 days “just by leaving [babies] with their mothers.”

But National Advocates for Pregnant Women executive director Lynn Paltrow said she believes real change won’t come until the United States has quality insurance coverage for mental-health and drug-dependency treatment and until parents feel safe admitting to drug use. Too many parents reasonably believe that seeking help for addiction could cause them to lose their children. “We want parents to ask for help,” she said. “But we can’t minimize the risk of harm by child-welfare authorities when they do.”

There’s hope that more family-friendly treatment can be built starting in October, when legislation, passed by Congress, provides unlimited federal-match funds to states for services that prevent children from entering foster care. Until now, only federal funds for foster care were unlimited, which incentivized removals. How much of a difference this will make, however, is anyone’s guess. Richard Wexler, the executive director of the National Coalition for Child Protection Reform, said the types of programs the legislation will reimburse are limited, and that the standard that drug-treatment programs will likely be required to meet may prevent smaller programs from accessing federal funds.

“We know how troubling from a brain-science perspective it is if bonding doesn’t happen,” said Alise Hegle, advocacy lead of the Children’s Home Society of Washington. She also said that parents’ bonds to their kids are often the most important driver of sobriety.

“I didn’t have visits with my daughter for the first year of her life,” Hegle recalled about the time she spent incarcerated for drug-related crimes. “But that first visit, when I laid my eyes on my daughter and watched her arms come out to me, was when I knew there was nothing and no one who would get in my way of being the best mom for this child.”