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Differential responsiveness to a parenting intervention for mothers in substance abuse treatment
Abstract
This study examines the relationship between levels of psychological distress in substance-dependent mothers and their differential response to a dyadic parent-child intervention. A sample of 66 mothers who were receiving treatment for substance abuse, as well as a simultaneous parenting intervention, were interviewed pre and post-treatment on measures of psychological distress, adult and child trauma history, parental reflective functioning, and child social-emotional development. Additionally, clinicians provided assessments of the parent-child relationships. As anticipated, trauma histories for mothers and children, children's social emotional development, and parental reflective functioning were associated with aspects of maternal psychological distress. Kruskal-Wallis and subsequent Wilcoxson signed rank tests revealed that women with highest levels of baseline psychological distress showed significant improvements in psychological functioning post-treatment while women with moderately elevated levels of psychological distress did not. Women who were most distressed at baseline showed increased levels of parental reflective functioning post-treatment while women with moderate and lower levels of baseline psychological distress showed improvements on clinician-rated assessments of parent-child relationships. Chi Square analyses showed that parents who endorsed the highest levels of distress at baseline reported that their children's risk status regarding social-emotional development decreased post-treatment. Despite similarities in substance dependence, mothers in this sample had different needs and outcomes in the context of this parenting intervention due to variation in mental health. Given this variation, parenting interventions for substance-dependent mothers need to account for the individual differences in levels of psychological distress.
... Unfortunately, evidence suggests that most adults who need substance use treatment do not receive it and that over 95% of adults who need but do not obtain treatment do not perceive that they need it (Park-Lee, Lipari, Hedden, Kroutil, & Porter, 2017). Moreover, mothers with SUDs frequently have co-occurring mental health disorders and high rates of trauma history that may further compromise parenting capacity (Connelly, Hazen, Baker-Ericzen, Landsverk, & McCue Horwitz, 2013;Faherty, Matone, Passarella, & Lorch, 2018;Paris, Herriott, Holt, & Gould, 2015). A growing body of research links past trauma with deficits in emotional regulation and interpersonal skills, for example (Van der Kolk, 2014). ...
... Although mental health needs are common among parents with SENs (Faherty et al., 2018;Paris et al., 2015), fewer than half of the interventions identified in this review were grounded in psychological theory. A psychotherapeutic approach may be important to address factors that have been shown to be associated with harsh parenting of infants and toddlers, such as maternal depression and hostile attributions (Berlin, Dodge, & Reznick, 2013), aggressive response biases (Berlin, Appleyard, & Dodge, 2011), low maternal sensitivity (Joosen, Mesman, Bakermans-Kranenburg, & van IJzendoorn, 2012), and childhood trauma history (Zvara, Mills-Koonce, Carmody, Cox, & Family Life Project Key Investigators, 2015). ...
... A psychotherapeutic approach may be important to address factors that have been shown to be associated with harsh parenting of infants and toddlers, such as maternal depression and hostile attributions (Berlin, Dodge, & Reznick, 2013), aggressive response biases (Berlin, Appleyard, & Dodge, 2011), low maternal sensitivity (Joosen, Mesman, Bakermans-Kranenburg, & van IJzendoorn, 2012), and childhood trauma history (Zvara, Mills-Koonce, Carmody, Cox, & Family Life Project Key Investigators, 2015). Notably, a growing body of theoretical and empirical literature also points to the value of attachment-based approaches that address caregiving skills (Paris et al., 2015;Suchman, 2016). It seems likely that successful interventions will require integrated theoretical models grounded in theories of psychology, attachment, social ecology, learning, and behavior to address the multiple underlying causes of child maltreatment in this population (Neger & Prinz, 2015;Suchman, Pajulo, DeCoste, & Mayes, 2006). ...
Substance-exposed newborns (SENs) are at increased risk of child maltreatment, out-of-home placement, and poor health and developmental outcomes. The purpose of this systematic review is to synthesize existing research on community- and home-based interventions designed to improve parenting and reduce risk of maltreatment for families with SENs, applying a program logic framework. The review includes studies that used preexperimental, quasi-experimental, and experimental designs. Twelve interventions were identified. Of the nine studies that used more rigorous experimental or quasi-experimental designs, five showed positive effects on at least one parenting or child maltreatment outcome, although some studies showed high risk of bias. Full coherence among the intended participants, theory of change, and program components was observed for only two interventions. The findings suggest a need for more rigorous research to develop and test interventions that are grounded in theory and prior research and that address the unique needs of families with SENs.
... In einer aktuellen Literaturrecherche konnten zehn verschiedene Programme gefunden werden, welche die Mentalisierung von Müttern mit psychischen Erkrankungen (Schechter et al., 2006;Paris, Herriott, Holt, Gould, 2015;Pajulo, Pajulo, Jussila, Eckholm, 2016;Suchman et al., 2017;Maupin et al., 2017), in Gefängnissen (Sleed, Baradon, Fonagy, 2013) oder mit erhöhtem Risiko (Sadler et al., 2013;Fonagy, Sleed, Baradon, 2016) sowie Familien in Präventionsprogrammen (Kalland, Fagerlund, von Koskull, Pajulo, 2016) und Familien mit missbräuchlichem Verhalten (Sleed u. Fearon, 2015) adressieren. ...
... B. Sadler et al., 2013), und in verschiedenen Settings für Familien, in Gruppen und auch in psychiatrischen Settings angeboten werden können (Schechter u. Serpa, 2014;Paris et al., 2015). ...
... Vier Programme konnten zeigen, dass die Mutter-Kind-Interaktion verbessert wurde (Sleed et al., 2013(Sleed et al., , 2015Pajulo et al., 2012;Huber, McMahon, Sweller, 2015;Suchman et al., 2017) und zwei Studien zeigten eine reduzierte psychopathologische Auffälligkeit des Kindes (Suchman et al., 2011;Paris et al., 2015). ...
Strengthening Attachment Competencies in Parents with Mental Illness: Adaptation and Pilot Testing of the Mentalization-Based Lighthouse Parenting Program Mentalizing describes the imaginative ability to understand human behaviour in terms of mental states. Parents with mental illnesses and experiences of early maltreatment frequently show impairments in mentalizing, which negatively impact their caregiving competences for the child. A number of mentalization-based programs to strengthen parental competences have been developed and most of them have been positively evaluated with regard to their efficacy. However, approaches which specifically aim to reach highly impaired families with children from different age groups and which can be implemented in psychiatric settings are currently lacking. The newly adapted mentalization-based Lighthouse-Parenting Program aims to fill this gap and strengthen competences of parents with a mental illness. The specific MBT-based stance, the structure and content of this new program are outlined and first results of a pilot test are presented. The program is a promising approach, which can easily be trained and implemented in existing mental health care systems. The Lighthouse-Parenting Program aims to improve the relationship between parent and child, to reduce parental stress and in the long-term to promote the child's development. A randomized controlled trial to evaluate the program's effectiveness is currently being planned.
... The increase in PRFQ Certainty of Mental States was similar to those found in other mentalizing interventions (Paris et al., 2015;Rostad & Whitaker, 2016). According to the authors of the PRFQ (Luyten, Mayes, Nijssens et al., 2017), high scores in Certainty can be linked to overconfident, intrusive attribution of mental states and low scores indicative of a deficiency in considering other people's mental states; both are of concern. ...
... That is, the cohort developed a slightly more healthy confidence in their ability to mentalize their infant. Other studies have found Certainty to be associated with reduced child social-emotional developmental risk (Paris et al., 2015) and improved parent-child relationship quality (Rostad & Whitaker, 2016), or to be unrelated to measures of maternal sensitivity to distress (Krink et al., 2018) and infant distress tolerance (Rutherford et al., 2013). ...
We report on two preliminary evaluations of a group intervention, targeting vulnerable
infants and their mothers within the first 6-months postpartum. The
Mother–Baby Nurture R program aims to strengthen the developing infant–mother attachment relationship by increasing maternal mentalizing. These studies were undertaken with pre-post evaluations with the mothers of infants under 10-months of age. The mother–infant dyads participated in ten 2-h group sessions. Study one (N = 69 dyads) included self-reported maternal depression, anxiety, and parenting confidence. In study two (N = 27 dyads), parenting stress and reflective functioning were measured by self-report, and reflective functioning coded on the 5 min speech sample (completed by N = 22). Results from study one confirmed a decrease in depression (p < .001, d = .79) and anxiety (p < .001, d = .72) symptoms, and an increase in mothers’ scores for parenting confidence (p < .001, d=−.98). Results from Study Two demonstrated a significant decrease in parenting stress (p < .001, d = .94) and significant improvement in measures of self-report reflective functioning (p = .007, .024; d = .56, .61). These findings are preliminary yet promising indications that this program could be effective in alleviating parenting stress, depression, and anxiety, and improving mother’s reflective functioning and parenting confidence. Further research is needed, with a control group and long-term follow-up assessments.
... On the contrary, Stacks et al. (2019) found that only those with the lowest pre-intervention PRF (≤3) showed increased PRF after an infant mental health home visiting intervention. This is in line with other findings that the most vulnerable individuals, such as those with trauma, attachment insecurity, or high psychological distress, may benefit more from parenting interventions than less vulnerable parents (Robinson and Emde, 2004;Paris et al., 2015;Stacks et al., 2019). ...
... Earlier studies similarly show mixed results regarding whether less or more vulnerable individuals benefit more from parenting interventions. Some studies suggest, similarly to our PRF results, that more vulnerable individuals benefit more from parenting interventions, perhaps simply because they need them more (Robinson and Emde, 2004;Paris et al., 2015;Stacks et al., 2019). Actually, Stacks et al. (2019) even found that only mothers with low PRF (3 or below) received benefits from their early home-visiting intervention. ...
Mothers with prenatal substance use disorder (SUD) often show broad deficits in their reflective functioning (RF), implying severe risk for the relationship with their baby. Two different types of prenatal maternal RF may be important for parenting: adult attachment-focused-RF (AAI-RF), regarding parent's own childhood experiences, and parenting-focused RF (PRF) regarding their own current process of becoming a parent. However, their inter-relations and potentially different roles for parenting intervention outcomes are not clear. This study examined the associations between mothers' prenatal AAI-RF and pre- and post-natal PRF, and their role in mother-infant interaction and substance use as treatment outcomes. The participants were 57 treatment-enrolled pregnant mothers with SUD and 50 low-risk comparison mothers. AAI-RF was measured with the Adult Attachment Interview. For a subsample of 30 mothers with SUD, PRF was measured with Pregnancy Interview (during pregnancy/pre-intervention), and with Parent Development Interview at 4 months (during intervention). Mother-infant interaction was measured with Emotional Availability Scales at 4 and 12 months (post-intervention), and maternal substance use by post-natal substance relapses. Prenatal AAI-RF and pre- and post-natal PRF were highly associated with each other. Only higher prenatal PRF predicted better mother-infant interaction quality at 4 months and less substance use during the child's first year. Interestingly, prenatal PRF and AAI-RF predicted opposite changes in mother-infant interaction: lower prenatal PRF, but higher AAI-RF predicting more positive change. AAI-RF was especially associated with a change in maternal intrusiveness and hostility, indicating that it represents a more general regulatory tendency. Further studies are needed in larger and lower-risk samples. Our results suggest, however, that AAI-RF and PRF are partially distinct and should be uniquely targeted in perinatal interventions.
... However, evidence suggests that such approaches may not adequately improve the quality of maternal-child interactions, attachment security, substance use, and psychiatric outcomes among mothers with SUDs in particular (Bosk et al., 2019;Suchman et al., 2006). In contrast, treatment models (e.g., Mothering from the Inside Out, Family Based Recovery, Project BRIGHT, Attachment and Biobehavioral Catch-up) that focus on strengthening mother-child relationships by improving maternal emotional self-regulation, decreasing parenting stress, increasing sense of satisfaction in parenting, and promoting associated positive parenting behaviors, show promise in improving the day-to-day interactions between mothers and their children (Berlin et al., 2014;Bosk et al., 2019;Hanson et al., 2015;Lowell et al., 2021;Paris et al., 2015). These parenting improvements can impact child health outcomes including increased parent-child dyadic reciprocity, increased child involvement in play with their parents, and improved child attachment security (Suchman et al., 2017). ...
... These models emphasize the role of the parent-child relationship in fostering child development and supporting caregivers' emotional needs. Models explicitly designed for parents with significant trauma or SUDs, such as Mothering from the Inside Out, Family Based Recovery, and Project BRIGHT (Hanson et al., 2015;Paris et al., 2015;Suchman et al., 2017), achieve these aims by emphasizing protection of the therapeutic relationship over instruction, given the potential that parents may perceive the providers as the 'better parent' and experience decreased parental self-efficacy or a defensive response in the therapeutic relationship (Lieberman et al., 2006;Lieberman & Van Horn, 2008). ...
Home visiting programs face many challenges when providing evidence-based services to families affected by substance use disorders (SUDs). We conducted interviews and focus groups with community stakeholders and parents to elucidate important considerations when intentionally attempting to meet the needs of families affected by SUDs through home visiting programs. We identified one primary theme “Who is the client?” that describes how to ensure caregivers perceive themselves as an important focus of the program. Collectively, participants revealed that understanding caregivers’ emotional experiences was critical for effectively transforming their subjective experiences of the program. These emotional experiences were related to the quality of their relationships with their children, other family members, and service providers. Three sub-themes illustrate specific examples: 1) responding to the unique emotional needs of mothers in recovery, 2) considering emotional states to inform inclusion in programs, and 3) addressing complex family dynamics related to SUDs in the home. Implications of these findings are discussed.
... A meta-analysis on the effects of parenting programs on child maltreatment prevention encompassing 37 studies provided evidence of positive effects and reduced risk of maltreatment [15]. Via own literature search, we found eleven different prevention programs that aim to enhance mentalizing in mothers with MI [16][17][18][19][20][21], in prison [22] or at other risk, such as teenage mothers [23], as well as in families [24,25] and in caregivers of inpatient psychiatric children [26]. The efficacy of four of these approaches that aim to prevent abuse by improving mentalizing in parents has been demonstrated in six randomized-controlled trials (RCTs) [16,21,22,25,27,28], and a further two RCTs are currently underway [26,29]. ...
... Previous studies have focused on mothers or parent-couples, leaving open the question of whether they are also successful with fathers. Even more importantly, although several studies have been performed in inpatient treatment settings for addiction [18,19], so far, no study has been conducted within general psychiatric hospitals for acutely MI parents with different diagnoses of the whole spectrum of mental disorders (e.g., depression, anxiety disorders, borderline personality disorder, addiction, schizophrenia). ...
Background
Parents’ mental illness (MI) and parental history of early life maltreatment (ELM) are known to be significant risk factors for poor parenting while poor parenting is a crucial mediator of the intergenerational continuity of child maltreatment. Hence, maltreatment prevention programs for families with an MI parent, which pay particular attention to experiences of ELM in the parent, are urgently needed. Parental mentalizing was previously found to mediate successful parenting. Interventions aimed at improving the parental mentalizing capacity reduced maltreatment risk in parents. The aim of the present study is to investigate the effectiveness of a mentalization-based parenting-counseling in acutely mentally ill parents currently treated at a psychiatric hospital.
Methods
Mentalization-based parenting-counseling (MB-PC) vs. enhanced standard clinical care (SCC+) will be administered in a cluster-randomized-controlled trial (RCT). Patients treated at psychiatric hospitals with children between 1.5 and 15 years will be included in the trial. MB-PC will be administered as a 12-h combined individual and group program enriched by social counseling (over a course of 5 weeks) as add-on to standard clinical care, while the control condition will be standard clinical care plus a 90-min psychoeducation workshop on positive parenting. Primary efficacy endpoint is self-reported parenting practices at follow-up. Embedded within the RCT will be two sub-studies investigating social cognition and dyadic synchrony as biobehavioral mechanisms of change.
Discussion
The main goal of the present study is to investigate ways to break the intergenerational continuity of maltreatment by assessing the benefits of a prevention program which aims at improving parenting in vulnerable mothers and fathers. MB-PC is a short, low-cost intervention which can be delivered by nurses and social workers and is applicable to MI patients with children with a broad range of diagnoses. If it is shown to be effective, it can be directly implemented into standard psychiatric hospital care thereby providing help to prevent child maltreatment.
Trial registration
German Clinical Trials Register DRKS00017398 . Registered on 5 July 2019
... Focusing treatment on the maternal mood disorder in isolation may not mitigate the developmental risks for infants [36], due to ongoing impaired mother-infant interaction styles (see [38] for a review). Dyadic interventions offer the opportunity to complement these treatments [39] by focusing on improving maternal sensitivity, leading to improvements in attachment security, children's cognition, and emotional regulation (e.g [40,41]). In particular, dyadic interventions using video feedback have been successfully employed as prevention programs to enhance maternal reflective functioning -the ability to understand and respond to infants' emotional states -improving emotional regulation and the quality of interactions (e.g [42,43]). ...
Background
Video feedback interventions have been designed to improve maternal sensitivity by reducing the negative effects of maternal depression symptoms on the quality of mother-infant interaction during the postnatal period. However, little is known about how these interventions may indirectly influence a mother’s sense of identity or who she understands herself to be.
Methods
Eight Australian women, with signs of perinatal depression, participated in a 3-session Video Interaction Guidance (VIG) intervention and a follow-up interview. Their interview responses were qualitatively analysed with a constructivist, inductive thematic analysis.
Results
VIG showed potential to support positive maternal self-concept, through its strengths-based approach. Women reported positive benefits, and their responses engaged with broader cultural discourses of “good” motherhood, which they both reflected and challenged. This process was supported by both the external evidence of the video clips and the insider validation of “seeing” the preferred sense of motherhood identity in action.
Conclusions
Findings expand the scope of VIG from its original aim of increasing maternal sensitivity, to that of indirectly assisting mothers with forming a more positive and durable sense of motherhood identity. Clinical implications and suggestions for the role of video feedback interventions in maternal depression are discussed, including the need for further research on VIG interventions in this group.
... In MBT-basierten Programmen wurden Studienergebnisseüber Aspekte der Adhärenz berichtet, z. B. dass eine mehr oder weniger stark ausgeprägte mentalisierende Haltung die Therapieergebnisse moderiere (Paris et al. 2015). Der Einsatz bestimmter Techniken, wie z. ...
Zusammenfassung
Die Mentalisierungsbasierte Therapie (MBT) ist eine evidenzbasierte integrative Therapie, die für die Behandlung von Patient:innen mit Borderline-Persönlichkeitsstörungen entwickelt wurde. In den letzten Jahren wurden das Verfahren auf andere Patient:innengruppen ausgedehnt. Im vorliegenden Beitrag stellen wir die neue Anwendung der MBT für Jugendliche mit Störungen des Sozialerhaltens vor (MBT-SSV), für die weitere Elemente, wie z. B. Familientherapie und Motivational Interviewing, in die Therapie integriert wurden. Im Rahmen einer Machbarkeitsstudie wurde überprüft, ob Therapeut:innen in Ausbildung verschiedener Grundorientierungen die MBT-SSV manualgetreu anwenden können. Dabei zeigten sich spezifische Anwendungsunterschiede in Abhängigkeit vom jeweiligen Verfahren.
... Parenting interventions and the support services offered to mothers with an OUD postnatally are also evolving to better meet the needs of these parents who often have associated financial difficulties, trauma and mental health challenges (Bosk et al., 2019;Paris et al., 2015Paris et al., , 2023Stulac et al., 2024). The current findings reinforce the critical need for these approaches and potential expansion, especially in the infancy and early childhood years. ...
Children born to mothers with opioid use disorder (OUD) are at increased risk of maltreatment and out-of-home care (OOHC) placement. This study examines the parent-child interaction quality and home environments of 92 New Zealand children with prenatal opioid exposure (OE) and 106 non-opioid-exposed (NE) children. Experiences for those in maternal care versus OOHC were of particular interest. Biological mothers completed a lifestyle interview during late pregnancy/at birth. At 18 months, parent-child interaction observations, maternal/primary caregiver interviews, and the Home Observation for Measurement of the Environment were completed during a home visit. At age 4.5, children underwent developmental assessment. By 18 months, 20% of OE children were in OOHC. Mothers with OUD who were younger, less cooperative, and had increased polysubstance use during pregnancy were more likely to have lost custody of their child. OE children in their mother's care experienced less positive parenting and lower-quality home environments than NE children. OE children in OOHC had similarly resourced environments to NE children, yet experienced lower levels of parental warmth and responsiveness. Early parenting predicted child cognition, language, and behavior 3 years later, underscoring the critical importance of supporting the parenting and psychosocial needs of OE children's parents/caregivers to improve long-term outcomes.
... Participants (N = 35) enrolled in this qualitative study were a subgroup of pregnant and postpartum people, all of whom identified as female, with substance use disorder including opioid use and polysubstance use. Participants were enrolled in a 12-month pragmatic randomized-controlled trial of the BRIGHT therapeutic parenting intervention (Building Resilience through Intervention: Growing Healthier Together; (Paris et al., 2015(Paris et al., , 2018. The RCT, entitled the Growing Together Study (clinicaltrials.gov, ...
The COVID-19 pandemic posed substantial challenges to all parents and families with children. However, women with substance use disorder (SUD) raising young children were particularly burdened, primarily stemming from their responsibilities and challenges concerning family and parenting, child welfare involvement, and substance use recovery. This qualitative study sought to elucidate the complex intersection among parenting, child welfare, and substance use treatment for pregnant and postpartum women raising young children during the pandemic. Participants were 35 women enrolled in a clinical trial of a therapeutic parenting intervention within a prenatal clinic for people with SUD. They were interviewed remotely using a semi-structured Coronavirus Pandemic Qualitative Interview protocol developed for the study. Following a thematic analysis approach, two coders analyzed transcribed interviews through line-by-line coding using NVivo 12. Findings revealed that participants encountered both similar and distinct challenges compared to the general population of families with young children during the pandemic. Like other families, they expressed struggles with typical life tasks and concerns over children’s health and development. Distinct to families managing substance use recovery, they described adverse interactions with the child welfare system, conflicting feelings about changes in substance use treatment, and positivity amidst uncertainty. Findings provide insight into the difficulties faced by families involved in the child welfare system managing parental SUD and recovery. Furthermore, they highlight the need to address more effectively the often-hidden struggles faced by this population through specialized interventions and greater collaborations among various services.
... Ghosh Ippen et al., 2011;Lavi et al., 2015), parental psychopathology (Fonagy et al., 2016), the risk of maltreatment (e.g. Toth et al., 2015), parental substance misuse disorders (Paris et al., 2015), and families with adopted children with Fetal Alcohol Syndrome Disorder (Zarnegar et al., 2016). In accordance with the complexity of difficulties being addressed, the interventions tend to be open-ended and relatively intensive, with most therapies being offered weekly for at least six months and often up to a year or beyond. ...
... Mentalizing describes one's ability to understand, interpret, and represent one's own and others' behaviors in terms of internal mental states (i.e., feelings, needs, and beliefs) (Fonagy et al., 1991;Slade, 2005). Mentalizing (also described as reflective functioning or reflective capacity when measured) has been identified as a critical capacity needed to establish secure attachment relationships and is a target of many attachment-focused interventions among parents with and without SUDs (Pajulo et al., 2006;Paris et al., 2015;Sadler et al., 2013;Stover et al., 2017;Zayde et al., 2021). MIO takes a bi-generational approach to mentalization by enhancing parents' capacities to reflect on their own and their child's mental states. ...
Attachment‐based interventions are important for improving parent‐child outcomes. These interventions must be scaled and made available to under‐resourced communities. An important part of scaling these interventions is delineating and reproducing high‐quality training, including clinical training which often requires the completion of a supervised case. However, descriptions and guidelines for clinical training are frequently broad or not available in the literature. A detailed description of clinical training could lead to further research to improve the effectiveness and dissemination of evidence‐based interventions. Mothering from the Inside Out (MIO) is an attachment‐based parenting intervention effective at reducing substance use and depression, improving caregiving, and enhancing child attachment. It is now being brought from research to community settings. This paper outlines the didactic and clinical training components of MIO. We then present a qualitative case study of one community‐based counselor participating in the clinical training of MIO and employ qualitative methods to describe the main themes that arose during the training. We aim to illustrate how the trainer assisted the counselor in implementing the core components of MIO, which included (a) refining the language used in MIO sessions, (b) making space to explore mental states, and (c) addressing trauma. We conclude by presenting the implications of these findings.
... In addition to the obvious need for more long-term evaluation studies, McCormick and colleagues' (2021) review also highlighted the need for greater attention to factors that moderate the effectiveness of programs for incarcerated parents and their families. This is particularly important given more general evidence suggesting that parenting interventions may differentially benefit subgroups based on race and ethnicity (Mogro-Wilson et al. 2019) and baseline levels of parental distress (Paris et al. 2015). ...
Parental incarceration is a significant, inequitably distributed form of adversity that affects millions of US children and increases their risk for emotional and behavioral problems. An emerging body of research also indicates, however, that children exhibit resilience in the context of parental incarceration. In this article, we review evidence regarding the adverse implications of parental incarceration for children's adjustment and consider factors that account for these consequences with special attention to naturally occurring processes and interventions that may mitigate risk and contribute to positive youth development. We also offer a critical reframing of resilience research and argue that (a) scholars should adopt more contextualized approaches to the study of resilience that are sensitive to intersecting inequalities and (b) resilience research and practice should be conceptualized as important complements to, rather than substitutes for, social and institutional change. We conclude by offering social justice–informed recommendations for future research and practice.
... Moreover, if motherchild relationships are supported, modeled, and strengthened, there will be decreased levels of stress and unresolved trauma that would otherwise trigger substance use in the future. [87][88][89] Studies in our review included pregnant and parenting women who use(d) alcohol, or alcohol and other substances, live with trauma, and accessed a support/service or initiative. However, there is very little research on pregnant or parenting women who are not accessing substance use-related supports or services, and/or who belong to middle and upper socio-economic classes where alcohol dependency is more hidden and women are not under social or child welfare surveillance. ...
Alcohol is legalized and used for a variety of reasons, including socially or as self-medication for trauma in the absence of accessible and safe supports. Trauma-informed approaches can help address the root causes of alcohol use, as well as the stigma around women's alcohol use during pregnancy. However, it is unclear how these approaches are used in contexts where pregnant and/or parenting women access care. Our objective was to synthesize existing literature and identify promising trauma-informed approaches to working with pregnant and/or parenting women who use alcohol. A multidisciplinary team of scholars with complementary expertise worked collaboratively to conduct a rigorous scoping review. All screening, extraction, and analysis was independently conducted by at least two authors before any differences were discussed and resolved through team consensus. The Joanna Briggs Institute method was used to map existing evidence from peer-reviewed articles found in PubMed, CINAHL, PsycINFO, Social Work Abstracts, and Web of Science. Data were extracted to describe study demographics, articulate trauma-informed principles in practice, and gather practice recommendations. Thirty-six studies, mostly from the United States and Canada, were included for analysis. Studies reported on findings of trauma-informed practice in different models of care, including live-in treatment centers, case coordination/management, integrated and wraparound supports, and outreach-for pregnant women, mothers, or both. We report on how the following four principles of trauma-informed practices were applied and articulated in the included studies: (1) trauma awareness; (2) safety and trustworthiness; (3) choice, collaboration, and connection; and (4) strengths-based approach and skill building. This review advances and highlights the importance of understanding trauma and applying trauma-informed practice and principles to better support women who use alcohol to reduce the risk of alcohol-exposed pregnancies. Relationships and trust are central to trauma-informed care. Moreover, when applying trauma-informed practices with pregnant and parenting women who use alcohol, we must consider the unique stigma attached to alcohol use.
... Enhancing maternal RF and ER are also included in BRIGHT. Women with the highest distress have shown a significant decrease in mental health symptoms and an improved RF as a result of this intervention [95]. Vazquez and Bergin [96.••] described their 90-day inpatient intervention program for substance-using pregnant women. ...
Purpose of Review
Maternal prenatal substance use presents a multilevel risk to child development and parenting. Although parenting interventions are increasingly integrated into substance use treatment, prenatal parenting processes have not received equal attention within these interventions. This article aims to synthesize the evidence on the specific prenatal risk factors affecting the development of early parenting of substance-using mothers, as well as interventions focusing on those factors.
Recent Findings
Both neurobiological and psychosocial risk factors affect the prenatal development of parenting in the context of maternal substance use. Maternal–fetal attachment, mentalization, self-regulation, and psychosocial risks are important in treatment and highly intertwined with abstinence. Although parenting interventions seem to be highly beneficial, most studies have not differentiated between pre- and postnatal interventions or described pregnancy-specific intervention elements.
Summary
Due to the salience of pregnancy in treating substance-using parents, interventions should begin prenatally and include pregnancy-specific parenting focus. Further research on prenatal interventions is warranted.
... To best meet the identified needs of mothers with addictions, a growing number of researchers and clinicians have recognized the utility of taking a reflective approach to intervention, grounded in the framework of mentalization [11,[48][49][50][51][52][53][54][55]. Mentalization is defined as the ability to make sense of behavior-in oneself and others-in terms of underlying thoughts, emotions, wishes, and intentions [56]. ...
Purpose of Review
Mothers with substance use disorders are often referred for parenting support, though commonly available programs may miss the mark for families impacted by addiction. This may be related to a lack of attention to children’s emotional needs, mothers’ histories of adversity, and the neurobiological differences seen in mothers with addictions. We review the implications of addiction, adversity, and attachment for parenting interventions. We then describe Mothering from the Inside Out (MIO), an evidence-based parenting intervention designed specifically for mothers with addictions.
Recent Findings
Evidence from clinical trials suggests that MIO improves outcomes for two generations: both mothers with addictions and their children. Recent trials demonstrate that MIO may be delivered effectively by community-based clinicians and may be beneficial for parents with other chronic stressors.
Summary
Addressing addiction, adversity, and attachment simultaneously may have a positive synergistic effect. Future research should study the implementation of MIO in real-world settings and examine the impact of MIO on maternal neurobiology.
... The parenting intervention domain has long been an area of research for social work scholars. Studies have examined programs that address parental mental health challenges, substance misuse, and vulnerability resulting from the effects of poverty (Harden & Whittaker, 2011;Paris, Herriott, Holt, & Gould, 2015;Paris, Spielman & Bolton, 2009). These studies all place primary importance on the parent-young child relationship and work to understand the effectiveness and mechanisms of change central to the intervention. ...
Infant and early childhood mental health (IECMH)—an interdisciplinary field dedicated to advancing understanding of early relationships, socioemotional development, and cultural and contextual influences on caregiving—offers essential tools for social workers to support the well-being of infants, toddlers, preschoolers, and their families. Even though social worker Selma Fraiberg was a founder of the field, and social workers are central to the work of assessment and intervention with young children and their caregivers in many settings, few schools of social work offer training in IECMH, and few social workers are familiar with its core principles, scholarship, and intervention approaches. In this article, faculty members from four U.S. social work programs address the vital role of IECMH in social work training, research, and practice as well as issue a call to the field to recover and renew commitment to a practice perspective and knowledge base with roots in social work. Twenty-five years ago, Social Work published a similar call, but the request has gone largely unheeded. The authors examine the changing landscape and argue that it is more important and timelier than ever for social workers to learn and integrate the relationship-based approach to promotion, prevention, intervention, and treatment offered by IECMH.
... Diversity also highlights the potential for differential responses to interventions. For example, studies indicate that certain parenting interventions may differentially benefit specific subgroups of parents based on race and ethnicity (Mogro-Wilson et al., 2019) or levels of parental distress at baseline (Paris et al., 2015). Children also have different needs at different ages, and interventions that are sensitive to and inclusive of different ages are essential. ...
The majority of research on children with incarcerated parents has focused on documenting main effects and adjustment problems among children and families. Although the focus on problems has been crucial in mobilizing support for this population, the field is now at a critical turning point where researchers are calling for more attention to resilience. We argue here that a family resilience perspective is useful in considering child and family level processes that may mitigate the harmful impact of parental incarceration. In contributing to a family resilience agenda, we first review evidence that points to parental incarceration as a risk to children. We then examine research that highlights children’s competence in the face of adversity as well as adaptive family processes, such as parenting and contact with the incarcerated parent, that contribute to children’s well-being. We offer recommendations for methodological innovation aimed at assessing competence, evaluating interventions, and incorporating multimethod approaches that capture dynamic processes and developmental change. We conclude with practice and policy implications and emphasize how a family resilience agenda suggests the need to contextualize developmental and family strengths within broader systems of discrimination and oppression.
... Discussions of the role of substance misuse, sobriety, and recovery in parenting are integrated throughout this work; thus, as an adjunct to substance abuse treatment, BRIGHT addresses mothers' substance abuse and trauma history and the role they play in the parentchild relationship. While outcome data for BRIGHT participants is limited, preliminary findings suggest that mothers who participate in BRIGHT have improved mental health and parenting capacities, and these improvements are most pronounced among those reporting the highest levels of baseline psychological distress (Paris et al. 2015). ...
In the first months and years of life, a young child’s relationship with his mother and other caregivers is critical and serves as the foundation for rest of the development. The postpartum period is a time of increased vulnerability to psychopathology for mothers, especially in the context of prior trauma. Trauma exposure, depression, and substance abuse can impede a mother’s ability to provide a kind of sensitive, responsive, attuned care that is necessary for her child’s optimal development. In this chapter, we discuss parenting processes among mothers with trauma exposure, depression, and substance abuse along with mother-infant therapeutic interventions that aim to improve mother-infant relationships in these at-risk populations to mitigate the intergenerational transmission of risk.
... The manner in which this pathway was addressed varied by parenting intervention. For example, eight programs offered facilitated playgroups (e.g., Pepler, Moore, Motz, & Leslie, 2002), structured activities (e.g., massage, Porter et al., 2015), or individual mother-child interaction with feedback (e.g., Berlin, Shanahan, & Appleyard Carmody, 2014;Paris, Herriott, Holt, & Gould, 2015), while three programs focused on mentalizing or increasing maternal reflection on a child's emotions, desires, and cognitions without the child present (Luthar & Suchman, 2000;Pajulo et al., 2011Pajulo et al., , 2012Suchman, Decoste, Rosenberger, & McMahon, 2012). No integrated programs in the community sample specifically shared that they designed their parenting intervention to increase pleasure in parenting role due to the potential neurobiological changes associated with chronic substance use. ...
Women with problematic substance use are frequently referred to interventions to promote positive parenting. Parenting interventions that attend to the unique risks faced by this population may enhance engagement and outcomes. While reviews of extant parenting interventions in the research literature have been undertaken, no studies have examined parenting interventions being implemented in community practice and the extent to which these are informed by current research. We systematically compared parenting interventions offered in 12 maternal substance use treatment programs in one Canadian province with those described in the research literature ( K = 21). Few parenting interventions were replicated, either within or across the two samples. However, parenting interventions within both samples were largely similar in their objectives. Across both research and community samples, approximately half of the interventions were developed or adapted for a problematic substance use population. Parenting knowledge, psychosocial risk, and maternal emotional regulation were most commonly addressed. Risks pertaining to the impact of drug craving and substance-related changes in neurobiology associted with parenting were less commonly addressed. Findings highlight current strengths and limitations of parenting interventions within research and community settings, with recommendations offered for future research and knowledge translation.
... Discussions of the role of substance misuse, sobriety, and recovery in parenting are integrated throughout this work; thus, as an adjunct to substance abuse treatment, BRIGHT addresses mothers' substance abuse and trauma history and the role they play in the parentchild relationship. While outcome data for BRIGHT participants is limited, preliminary findings suggest that mothers who participate in BRIGHT have improved mental health and parenting capacities, and these improvements are most pronounced among those reporting the highest levels of baseline psychological distress (Paris et al. 2015). ...
... In the last few years, mentalization-and attachment-based parent-child treatments have been investigated regarding their efficacy in increasing mentalizing and the parent-child relationship, especially in vulnerable parents (Camoirano, 2017). Interventions encompass the use of specific techniques that promote RF as a key mechanism for a parent to become attuned to his or her child's emotional and behavioral needs (e.g., Paris, Herriott, Holt, & Gould, 2015). However, it is still not known which therapeutic interventions specifically promote parents' ability to mentalize. ...
Parent–infant psychotherapy treats parents to reduce infants’ symptoms and strengthen the quality of the parent–infant relationship. However, little is known about the change processes that are set in place in parent–infant psychotherapy and the therapeutic techniques that are most helpful. The aim of this study was to provide a comprehensive description of the course of one treatment with a depressed mother of an 8 months old infant who received focused parent–infant psychotherapy (fPIP), a brief psychological intervention that aims at fostering mentalizing in the parent. This study also aimed at examining the specific interventions that fostered mentalizing in this case. We assessed therapeutic interventions with the fPIP adherence scale and in‐session mentalizing with the Reflective Functioning Scale, and we analyzed qualitatively the moments in therapy that were relevant for the treatment focus and during which the mother demonstrated an increase in reflective functioning. We discussed the results with regard to the processes in the course of treatment and the strengths and limitations of fPIP.
... Other research with mothers diagnosed with substance use disorders or postpartum depression recommends that providers find a balance between the competing needs of the mother for self-exploration and the needs of the parent-child dyad (Paris et al., 2011(Paris et al., , 2015. Having the child in sessions naturally directs focus to the child's experience and offers the parent an opportunity to explore their feelings about parenting generated by dynamics in the moment. ...
To meet the needs of families who have very young children and are involved with child protective services due to substance use, the State of Connecticut Department of Children and Families, Yale Child Study Center and Johns Hopkins University created an innovative treatment model. This public–private collaboration required a paradigm shift for both child protective services staff and treatment providers. This brief description of the Family‐Based Recovery model highlights the family‐focused practice elements that allow children to remain safely at home with parents who are in treatment. Outcomes suggest that Family‐Based Recovery is a promising practice, and collaborations between child protective services and substance use treatment providers can yield positive results for families with young children.
‘Highlights the family‐focused practice elements that allow children to remain safely at home with parents who are in treatment’
Key Practitioner Messages
• Strong collaboration between child protective services and treatment providers can mitigate the risk of out‐of‐home placement for children impacted by parental substance use.
• In‐home treatment that provides concurrent psychotherapy, substance use treatment and parent–child dyadic therapy is an important part of the service array for families involved with child protective services.
... 35 In addition to impairments caused by drug and alcohol use, the extensive co-morbidity of depression and post-traumatic stress disorder among women with substance use disorders causes emotional distress that influences the quality of attachment as well as parental interactions with their child. 36 In combination with their own substance use and limited social support, mothers recovering from addiction face extraordinary demands. 37 Children may experience discontinuity of parental care through separations that occur with child welfare placement, substance use relapse, parental incarceration, and parents' difficulty in being consistently physically and emotionally present in a way that is essential to healthy child attachment and development. ...
Opioids and Child Welfare Across the country, placements in foster care are rising. In 2016, the U.S. Department of Health and Human Services reported that 273,539 children in the U.S. entered foster care. In 34 percent of those cases, parental drug abuse was one of the factors leading to the child’s removal from their family. Additionally, the U.S. Substance Abuse and Mental Health Services Administration estimates that 400,000 births nationally are affected by prenatal exposure to alcohol and illicit drugs, which represents 10 percent of all live births. As the opioid epidemic continues, increasing numbers of children are at high risk for developmental and behavioral disorders because of their prenatal substance and alcohol exposure. In addition, children who remain at home may endure the challenges and trauma resulting from impaired caregiving due to parental substance use disorders (SUDs). This article explores the intersection of the opioid epidemic and child welfare, examining current research and publicly available data to discuss policy opportunities for better serving families affected by parental SUDs, including: ensuring health and safety for infants prenatally exposed to substances; appropriate identification, diagnosis, and treatment of developmental and behavioral needs; ensuring parents have access to outpatient treatment and services that can allow families to stay together when safe and appropriate; and ensuring sufficient access to inpatient treatment options that can serve parents and children together.
... In response to neuroscientific evidence showing that alterations in neural reward circuitry associated with chronic substance use affect a mother's response to her infant (see Kim et al., 2017;Rutherford, Williams, Moy, Mayes, & Johns, 2011), clinical scientists have increasingly been developing and testing parenting interventions that target psychological deficits associated with early stages of recovery from addiction, including emotional dysregulation and dysphoria, poor impulse control, and the absence of hedonic reward associated with caregiving. Many of these efforts target the parent's capacity to mentalize, or make sense of the emotional distress associated with pregnancy and parenting, in order to help parents who are in addiction recovery regulate strong emotions during stressful parenting situations (Pajulo, Pajulo, Jussila, & Ekholm, 2016;Paris, Herriott, Holt, & Gould, 2015;Stover, Carlson, & Patel, 2017). ...
This study evaluated methods for training community-based clinicians to deliver a mentalization-based parenting intervention in an addiction treatment setting. Mothering from the Inside Out (MIO) targets psychological deficits associated with early stages of addiction recovery by fostering improvement in parental reflective functioning, the capacity to make sense of strong emotions in oneself and the child. Fifteen addiction counselors were randomized to training in MIO versus a Parent Education comparison, and completed eight training sessions and a clinically-supervised 12-session training case. As predicted, MIO and PE counselors demonstrated fidelity to their respective interventions during the training case. At the end of training, MIO counselors showed greater improvement than PE counselors in clinical reflective functioning, the capacity to make sense of a patients’ mental and emotional experiences. Implications for training community-based counselors in evidence-based attachment interventions are explored.
... In a small group of mothers (N = 21) Berlin et al. (2014) found their intervention increased sensitive parenting behavior. (Paris et al., 2015) found that mothers reported a decrease in psychological distress, with the greatest decrease reported by mothers initially displaying the highest level of psychological distress. ...
Background:
There is growing interest in the provision of parenting support to substance misusing parents.
Methods:
This pragmatic, multi-center randomized controlled trial compared an intensive one-to-one parenting program (Parents under Pressure, PuP) with Treatment as Usual (TAU) in the UK. Parents were engaged in community-based substance misuse services and were primary caregivers of children less than 2.5 years of age. The primary outcome was child abuse potential, and secondary outcomes included measures of parental emotional regulation assessed at baseline, 6 and 12-months. A prospective economic evaluation was also conducted.
Results:
Of 127 eligible parents, 115 met the inclusion criteria, and subsequently parents were randomly assigned to receive PuP (n = 48) or TAU (n = 52). Child abuse potential was significantly improved in those receiving the PuP program while those in TAU showed a deterioration across time in both intent-to-treat (p < 0.03) and per-protocol analyses (p < 0.01). There was also significant reliable change (recovery/improvement) in 30.6% of the PuP group compared with 10.3% of the TAU group (p < 0.02), and deterioration in 3% compared with 18% (p < 0.02). The probability that the program is cost-effective was approximately 51.8% if decision-makers are willing to pay £1000 for a unit improvement in the primary outcome, increasing to 98.0% at a £20,000 cost-effectiveness threshold for this measure.
Conclusions:
Up to one-third of substance dependent parents of children under 3-years of age can be supported to improve their parenting, using a modular, one-to-one parenting program. Further research is needed.
... In a small group of mothers (N = 21) Berlin et al. (2014) found their intervention increased sensitive parenting behavior. (Paris et al., 2015) found that mothers reported a decrease in psychological distress, with the greatest decrease reported by mothers initially displaying the highest level of psychological distress. ...
The Parents under Pressure program was developed in Australia for families facing multiple difficulties including parental substance abuse and potential or actual engagement in the child protection system. This study was undertaken in the UK to determine if findings from Australian studies could be replicated. Importantly, the PuP program was delivered by routine practitioners thus this pragmatic trial combined the rigours of an efficacy trial with real world delivery as in effectiveness trials. There were significant differences across a range of analytic strategies on the primary outcome measure, indicating that engagement in the PuP program produced improvements than treatment as usual. Limitations of the study include a relatively short term (12month) followup.
... In a small group of mothers (N = 21) Berlin et al. (2014) found their intervention increased sensitive parenting behavior. (Paris et al., 2015) found that mothers reported a decrease in psychological distress, with the greatest decrease reported by mothers initially displaying the highest level of psychological distress. ...
Working with Vulnerable Families - edited by Fiona Arney September 2013
... These observations are promising, but require more rigorous investigation, with the caveat that our ability to measure change in pRF is limited. Treatment programs using pRF as an outcome measure have seen limited results, with change only seen in those with the lowest pRF scores before the intervention (Slade et al. 2005a, b) or with the greatest levels of pre-treatment psychological distress (Paris et al. 2015). Others have found no improvement in pRF (Fonagy et al. 2016). ...
Evidence-based interventions for infants and preschoolers, and their families, have largely focused on the mother-child dyad. In response to the increasing need to diversify treatment approaches in the under six population and include the whole family system, we have developed a new treatment approach called Reflective Family Play (RFP). A manualized, whole-family therapy, RFP allows for the involvement of two parents and siblings when working with infants or young children. In this case-series, we used a qualitative chart review to examine the therapeutic process, acceptability, and feasibility of RFP for 22 families with children ages 0–6, who participated in RFP. We also sought to better understand the referral characteristics of those families who participated in RFP by comparing them to families who were referred to and participated in an established dyadic approach during the same time-period. Session-by-session coding of clinician chart notes revealed evidence of positive shifts throughout the RFP process, including more whole-family play, improvements in coparenting, and better parental mentalization. Parents reported improvements in presenting concerns in all but one case. Improvements in coparenting, sibling relationships, and family alliance were also reported by parents after RFP. Clinical implications and directions for future research are discussed.
... Die elterliche Mentalisierungsfähigkeit beschreibt die Kapazität von Eltern das Verhalten ihres Kindes hinsichtlich seiner/ihrer mentalen Zustände zu verstehen (Sharp & Fonagy, 2008;Slade, 2005). Der reflexive Prozess ermöglicht es, dass Eltern Intentionen, Bedürfnisse, Wünsche und Gefühle hinter dem Verhalten ihres Kindes erkennen sowie über ihre eigenen mentalen Erfahrungen und deren Beeinflussung und Veränderung durch die Interaktionen mit dem Kind zu reflektieren ( Luyten et al., 2017a Stichproben als stabil und das Instrument ist hinreichend valide und reliabel, auch für den Einsatz in klinischen Stichproben (Paris, Herriott, Holt, & Gould, 2015). Cronbach's Alpha in der vorliegenden Studie liegt bei α = .59 ...
Parental Reflective Functioning and its Relation to Parenting Stress in a Sample with Early Regulatory Disorders Parents' capacity to reflect on their child as a mental agent, is defined as an important competence for the early parent-infant relationship. One way to operationalize this is parental reflective functioning (PRF) that distinguishes between mentalizing and non-mentalizing modes of reflection. Until today PRF has not been investigated in samples of infants/toddlers with early regulatory disorders. Goal of the present study is to investigate PRF by comparing a clinical group with parents of infants/toddlers with early regulatory disorders (N = 98) with a healthy control group (N = 27) and testing if PRF is related to parenting stress, past mental illness of the mother, and stress factors related to pregnancy and birth. A semi-structured clinical interview, the Parenting Stress Index, the Symptom-Check-List-90R-S, the Parental Reflective Functioning Questionnaire, and an anamnestic questionnaire were used. Compared to the control group, mothers of infants/toddlers with early regulatory disorders reported significant more prementalizing. Prementalizing in the total sample was significantly predicted by parenting stress, accounting for 16.3 % of the variance. None of the other independent variables significantly predicted prementalizing. Results are discussed in relation to early regulatory disorders and implications for clinical practice.
... While no study has specifically examined the outcomes of children of suicidal mothers with an SUD, children of mothers with mental health struggles, in addition to a SUD are at an even greater risk for negative outcomes compared to children of mothers with only a SUD (Hser et al. 2015;Luthar et al. 1998;Luthar and Sexton 2007). Additionally, Paris et al. (2015) recently reported that mothers with an SUD responded differently to a parenting intervention depending on their level of mental distress. This suggests that children of mothers with a SUD and children of mothers with a SUD and a comorbid mental health diagnosis may have differing needs, and the impact of mother's mental health should be considered when developing interventions. ...
Suicidal thoughts and behaviors are common among women with a substance use disorder (SUD). Additionally, a significant number of women substance users have children in their care. While the negative impact of maternal substance use on child outcomes has been documented, little is known about how the co-occurrence of suicidal ideation influences child outcomes. The current study examined the relationship between parenting behaviors and child outcomes in a sample of 183 treatment seeking women with a SUD who had a child in their care. Findings showed that maternal autonomy promotion, maternal acceptance and parental monitoring were associated with decreased child behavior problems. However, the presence of maternal suicidal ideation presented unique risk in which children generally did not benefit from positive parenting behaviors. The findings imply that children of suicidal mothers who also have a SUD could benefit from different parenting strategies than children of mothers who are not suicidal. This study suggests that suicidal ideation is a unique risk factor that should be addressed with both mothers and children when mothers seek substance use treatment.
... Number of sessions can vary, but optimally, the parent and child meet with the clinician for approximately 9-12 months, although progress has been noted with as few as 10-12 sessions. Early findings demonstrate that BRIGHT is associated with improvements in maternal mental health and parenting capacities ( Paris, et al., 2015). BRIGHT is informed by principles and techniques of the evidence-based Child-Parent Psychotherapy (CPP, Lieberman & Van Horn, 2004;Toth, Rogosh, et al., 2006) and strategies derived from infant mental health interventions for vulnerable parent-infant dyads (e.g., Slade, et al., 2005) including parents with SUDs ( Suchman, et al., 2010). ...
... Finally, although two studies have provided preliminary evidence that the PRFQ subscales are sensitive to change [105,106], further research is needed to investigate the potential of the PRFQ to measure changes in parental reflective functioning as a result of psychosocial interventions. ...
This paper reports on three studies on the development and validation of the Parental Reflective Functioning Questionnaire (PRFQ), a brief, multidimensional self-report measure that assesses parental reflective functioning or mentalizing, that is, the capacity to treat the infant as a psychological agent. Study 1 investigated the factor structure, reliability, and relationships of the PRFQ with demographic features, symptomatic distress, attachment dimensions, and emotional availability in a socially diverse sample of 299 mothers of a child aged 0–3. In Study 2, the factorial invariance of the PRFQ in mothers and fathers was investigated in a sample of 153 first-time parents, and relationships with demographic features, symptomatic distress, attachment dimensions, and parenting stress were investigated. Study 3 investigated the relationship between the PRFQ and infant attachment classification as assessed with the Strange Situation Procedure (SSP) in a sample of 136 community mothers and their infants. Exploratory and confirmatory factor analyses suggested three theoretically consistent factors assessing pre-mentalizing modes, certainty about the mental states of the infant, and interest and curiosity in the mental states of the infant. These factors were generally related in theoretically expected ways to parental attachment dimensions, emotional availability, parenting stress, and infant attachment status in the SSP. Yet, at the same time, more research on the PRFQ is needed to further establish its reliability and validity.
... Die Substanzabhängigkeit eines Elternteils gilt in der Literatur als einschlägiger Risikofaktor für sowohl kognitive als auch sozial-emotionale Entwicklungsabweichungen (Beckwith et al., 1994;McNichol u. Tash, 2001;Nair, Schuler, Black, Kettinger, Harrington, 2003;Paris, Herriott, Holt, Gould, 2015). Störungen durch Substanzkonsum können zu vielfältigen Belastungen führen, die mit Einschränkungen in der emotionalen Verfügbarkeit, der Versorgung, oder der Erziehungsfähigkeit insgesamt einhergehen (Hynan, 2014;Kandel, 1990;Miller, Smyth, Mudar, 1999;Suchman u. ...
Psychologists can make an important contribution to decision making in custody and access proceedings by providing expert opinions to the courts, addressing the best interests of the child. This study aims to investigate quantified effects of indicators on recommendations of psychological evaluators in custody and access proceedings. This data is based on 179 psychological evaluations that were conducted from 2008 to 2012 at an evaluator association in Bremen, Germany. The data is assessed in a quantitative content analysis. Using logistic regression analysis, the influence of childand parent-related factors on the recommendations of the evaluators is investigated both in custody and in access proceedings. In cases addressing child custody, substance abuse and dependency of the mother and a child’s preference for living with the father are significant predictors for the evaluators’ recommendation. In cases concerning visitation rights, the child refusing contact with the father and the child experiencing physical abuse are identified as significant predictors. In the present study, the effects of relevant factors on the recommendation of psychological evaluators in family proceedings were first examined on a German sample. This study thus makes an important contribution to the empirical research in the field of psychology and family law.
... Die Substanzabhängigkeit eines Elternteils gilt in der Literatur als einschlägiger Risikofaktor für sowohl kognitive als auch sozial-emotionale Entwicklungsabweichungen (Beckwith et al., 1994;McNichol u. Tash, 2001;Nair, Schuler, Black, Kettinger, Harrington, 2003;Paris, Herriott, Holt, Gould, 2015). Störungen durch Substanzkonsum können zu vielfältigen Belastungen führen, die mit Einschränkungen in der emotionalen Verfügbarkeit, der Versorgung, oder der Erziehungsfähigkeit insgesamt einhergehen (Hynan, 2014;Kandel, 1990;Miller, Smyth, Mudar, 1999;Suchman u. ...
Zusammenfassung Psychologische Sachverstandige konnen in Sorge- und Umgangsrechtsverfahren einen wichtigen Beitrag leisten, indem sie Gerichten am Kindeswohl orientierte Einschatzungen liefern. Ziel der vorliegenden Arbeit ist es, quantifizierte Effekte von Einflussfaktoren auf die Empfehlung psychologischer Sachverstandiger in Sorgerechts- und Umgangsrechtsverfahren an einer deutschen Stichprobe zu untersuchen. Grundlage fur die vorliegende Erhebung sind 179 psychologische Sachverstandigengutachten, die im Zeitraum von 2008 bis 2012 an einem Bremer Gutachterinstitut in Verfahren zum Sorge- und zum Umgangsrecht erstellt wurden. Die Datenerhebung erfolgt nach der quantitativen Inhaltsanalyse. Mittels logistischer Regressionsanalysen wurde der Einfluss kind- und elternbezogener Faktoren auf die Empfehlungen der Sachverstandigen sowohl in Sorge- als auch in Umgangsrechtsverfahren untersucht. In Fallen, denen eine sorgerechtliche Fragestellung zugrunde liegt, erweisen sich das Vorliegen einer Substanzabhangig...
... Ashton et al. (2016) found an improvement in parental reflective functioning in mothers who underwent intensive group intervention (Trauma and Attachment Group; TAG) for caregiver/child dyads. On the contrary, in a sample of substance-abusing mothers, Paris et al. (2015) reported that PRFQ scores revealed a significant improvement only in mothers who had shown higher levels of psychological distress at the beginning of a brief dyadic parent-child intervention. A prenatal version (Prenatal Parental Reflective Functioning Questionnaire; P-PRFQ) consisting of 14 items was recently developed by Pajulo et al. (2015). ...
In the last decade several studies have investigated the role of parental reflective functioning (RF), defined as the parental ability to understand his/her child’s mental states, on the child’s development. Herein, a narrative review on parental RF is presented aimed at (1) presenting an overview of the existing empirical studies, (2) pinpointing unrequited questions, and (3) identifying future research directions. Specifically, the current review focused on (a) the impact of parental RF on the quality of caregiving and the child’s attachment security, (b) the effect of parental RF on the child’s emotion regulation and the child’s RF, (c) maternal RF in women with a history of neglect and abuse, (d) the efficacy of mentalization-based clinical interventions, and (e) the recently developed Parental Reflective Questionnaire. The following terms “maternal RF,” “paternal RF,” “parental RF,” “parental mentalization,” “maternal mentalization,” and “paternal mentalization” were searched in titles, abstracts, and main texts using Medline, Web of Science, and Scopus databases. Next, a search in Mendeley was also conducted. Inclusion criteria comprised original articles if they refer to the RF Scale (Fonagy et al., 1998) and were published in an English language, peer-reviewed journal before July, 2016. According to exclusion criteria, dissertations, qualitative or theoretical papers, and chapters in books were not taken into account. The review includes 47 studies that, taken together, supported the notion that higher parental RF was associated with adequate caregiving and the child’s attachment security, whereas low maternal RF was found in mothers whose children suffered from anxiety disorders, impairment in emotion regulation, and externalizing behaviors. In addition, higher parental RF was associated with better mentalizing abilities in children. However, unexpected findings have emerged from the most recent randomized controlled trials that tested the efficacy of mentalization-based interventions in high risk samples of mothers, raising questions about the suitability of the verbal measures in capturing the mentalizing processes at the root of the parental capacity to be adequately responsive to the child’s emotional needs.
Support for families affected by substance use disorders (SUDs) remains challenging, particularly during the postpartum period. The objective of this study was to assess the introduction of an evidence‐based parenting intervention, Mothering from the Inside Out (MIO), into the early intervention (EI) home visiting setting. We conducted a mixed methods pilot study in the United States to assess the training and delivery of MIO within EI. MIO training involves didactic learning followed by MIO delivery with weekly consultation. Our primary implementation outcomes were feasibility, acceptability, and factors influencing adoption. We assessed feasibility and fidelity via quantitative measures, and acceptability and adoption via qualitative interviews with providers and parents. Two cohorts of EI providers completed the didactic training: 2019 (in‐person) and 2020 (virtually). Ten providers participated in the MIO didactic training and began delivering MIO to 11 mothers; 4 of 10 providers (2 from each cohort) completed the full training. All providers that completed achieved adequate fidelity. Acceptability of MIO and perceived fit within EI was high, though challenges related to complexity limited adoption. Despite encouraging preliminary findings that EI providers achieved adequate adoption and fidelity, further adaptations are needed to address implementation challenges and improve retention of providers and parents.
Introduction
Online-based interventions provide a low-threshold way to reach and support families. The mentalisation-based Lighthouse Parenting Programme is an established intervention aimed at preventing psychopathological development in children. The objective of this study is to examine the feasibility of an online adaptation of the Lighthouse Parenting Programme (LPP-Online), evaluating (a) recruitment capability, compliance, acceptability and satisfaction with the intervention; (b) the psychometric properties of and the acceptability regarding the adjunct psychological evaluation; and (c) the employed materials and resources. The study will also obtain a preliminary evaluation of participants’ responses to the intervention.
Method and analysis
In this monocentric, one-arm, non-randomised feasibility trial, n=30 psychologically distressed parents with children aged 0 to 14 years will participate in the LPP-Online for a duration of 8 weeks. The intervention consists of online group sessions and individual sessions, 38 smartphone-based ecological momentary interventions (EMI), and psychoeducational materials (website, booklet). At baseline (T0) and the end of the intervention (T1), parents complete self-report questionnaires as well as 7-day ecological momentary assessments (EMA) via smartphone. During the intervention, additional EMA are completed before and after the daily EMI. An interview regarding parents’ subjective experience with the intervention will be conducted at T1. The feasibility of the intervention, the psychological evaluation and the resources will be examined using descriptive and qualitative analyses. The preliminary evaluation of the parents’ response to the intervention will be conducted by analysing pre–post changes in questionnaire measures and the 7-day EMA as well as data of additional EMA completed before and after the daily EMI.
Ethics and dissemination
Ethical approval of the study has been obtained from the local ethics board (Faculty of Behavioural and Cultural Studies, University of Heidelberg). Consent to participate will be obtained before starting the assessments. Results will be disseminated as publications in peer-reviewed scientific journals and at international conferences.
Registration details
German Clinical Trials Register (DRKS00027423), OSF ( https://doi.org/10.17605/OSF.IO/942YW ).
Objectives
Two key parental reflective capacities—mindful parenting (MP) and parental reflective functioning (PRF) — have been shown to promote healthy parent-child relationships through parents’ increased sensitivity and responsiveness to their children’s needs in spite of parenting stressors. Despite the theoretical overlap between these two constructs, researchers have continued to examine them independently. Therefore, the purpose of this scoping review was to review the overlapping and distinctive outcomes and correlates in the empirical MP and PRF literatures.
Method
A comprehensive literature search across the MP and PRF literature for studies published from 2005 through early 2020 (pre-COVID-19 pandemic) was conducted.
Results
A review of 301 articles (n = 180 MP and n = 121 PRF) revealed overlapping study outcomes and correlates, including improvement in parent and child well-being, parenting behaviors, and attachment. Both MP and PRF literatures suggest MP and PRF are amenable to intervention-induced changes, although mostly documented in White mothers, which results may not be generalizable to diverse populations.
Conclusions
Researchers should consider the impact MP and PRF have on positive family relationships. Results suggest that scholars should consider investigating and intervening on MP and PRF simultaneously. Specifically, results identified MP and PRF convergent associations and perhaps synergistic impacts on positive parenting behaviors. Limitations and future directions are discussed.
Preregistration
This review was not preregistered.
Posttraumatic stress symptoms are prominent in the lives of parents of young children with substance use disorders (SUD). Parenting experiences, particularly stress and competence, impact parenting behaviors and concomitant child growth and development. Factors that promote positive experiences of parenting, such as parental reflective functioning (PRF), and protect the mother and child from negative outcomes are crucial to understand to develop effective therapeutic interventions. The current US study analyzed baseline data from a parenting intervention evaluation to examine how length of substance misuse, PRF, and trauma symptoms were associated with parenting stress and parenting sense of competence among mothers in treatment for SUDs. Measures included the Addiction Severity Index, PTSD Symptom Scale‐Self Report, Parental Reflective Functioning Questionnaire, Parenting Stress Index/Short Form, and Parenting Sense of Competence Scale. The sample included 54 predominantly White mothers with SUDs who had young children. Two multivariate regression analyses found that (1) lower parental reflective functioning and higher posttraumatic stress symptoms were associated with higher parenting stress, and (2) only higher posttraumatic stress symptoms were associated with lower levels of parenting sense of competence. Findings underscore the importance of addressing trauma symptoms and PRF when aiming to improve parenting experiences for women with an SUD.
Mental health professionals encounter many patients with mental disorders who are also parents. Parenting is often more challenged in parents with mental disorders, but can also motivate change. In family treatment parents with a wide range of mental illness are seen. To guide mental health professionals in their service provision to patients who are also parents, a literature search was conducted for an overview of interventions for parents with a broad range of mental illnesses. One hundred twenty-seven studies were found. Most studies focused on interventions for participants with a single disorder without comorbid problems: mostly depression (62 studies). Almost no interventions for parents with personality disorders and none for parents with autism were found. Described interventions focused mostly on improving the quality of the parent–child relationship, and to a lesser extent on improving psychological well-being of the parent or child behavior. Most interventions to improve the quality of the dyadic parent–child relationship used an attachment-based framework, especially for younger children. For improving parental psychopathology cognitive behavioral techniques were mostly used, and effective. Treatment will likely work reciprocally: improved parenting skills will also improve parental psychopathology and vice versa. Generally, the duration of the intervention was associated with the severity of family problems. New ways for (group) treatment may be found in online interventions. Inclusion of the partner or other family members in treatment has been found to be beneficial. Most studies did not include a long follow-up period, and the ones that did usually showed that effects did not last.
The aim of the current study is to explore factors associated with quality of parenting among women in treatment for opioid use disorders. 150 Black American women with 3–5 year old children were recruited through methadone treatment programs. Parenting representations were assessed through the Working Model of the Child Interview and parenting behavior through video recordings of mother–child interaction. Interviews were used to assess mothers’ history of violence exposure and to make DSM diagnoses. Mothers’ mood disorder was related to distorted representations and to expressions of concerned affect (anxiety, fear, guilt). Mothers’ personality disorder was related to expressions of negative affect (anger and frustration) and inversely related to sensitive parenting behavior. Mothers’ experience of family violence during childhood and partner violence during adulthood were related to concerned affect in their representations. Women in treatment for substance use disorder have complex and interconnected needs, including parenting supports and trauma-informed mental health services.
Advances in developmental psychology, child psychiatry, and allied disciplines have pointed to events and experiences in the early years as the origin of many adult mental health challenges. Yet, children’s mental health services still largely lack a developmental or prevention-focused orientation, with most referrals to mental health professionals occurring late, once problems are well established. An early childhood mental health system rooted in the principles of life-course health development would take a very different approach to designing, testing, and implementing prevention and intervention strategies directed toward early child mental health. Priorities for such a system include supporting healthy family environments, parent–child and family relationships, parents’ emotional/behavioral health, and family routines as a means of providing the best possible neurobiological foundation for mental health across the life span. The system would include proactive, trauma-informed, multidisciplinary care, with integrated mental health and social services support embedded in pediatric primary care settings. Novel intervention approaches in need of further research include 2-generational dyadic interventions designed to improve the mental health of parents and children, mental health-oriented telemedicine, and contingency management (CM) strategies. Integral to this Life Course Health Development reformulation is a commitment by all organizations supporting children to primordial and primary prevention strategies to reduce racial and socioeconomic disparities in all settings. We contend that it is the family, not the individual child, that ought to be the identified target of these redesigned approaches, delivered through a transformed pediatric system with anticipated benefits for multiple health outcomes across the life course.
Providers across disciplines need knowledge, attitudes, confidence and resources to communicate and collaborate effectively when working with families with infants affected by substance use. This pre-post study assessed the acceptability, perceived utility, and preliminary outcomes of a hybrid online and in-person interprofessional training program for 104 providers working in child welfare, Early Intervention, and maternal and early childhood home visiting programs. Participants completed a baseline self-report pretest survey, a hybrid online and in-person training program, and a posttest survey. Quantitative data were analyzed using paired t tests; qualitative data from open-ended questions were analyzed using thematic coding. Quantitative data indicated improvements in knowledge and confidence across all provider types, and improvements in home visitor and early intervention providers’ perceptions of having the resources to collaborate with child welfare. Overall, the training was described as acceptable and useful. Findings provide initial support for interprofessional training to improve provider competence and collaborative capacity for working with families and infants affected by substance use.
Purpose
This community‐based participatory research project explored the feasibility of delivering parenting and recovery supports through digital technology for mothers recovering from addictive substances.
Design and Methods
A community advisory board of key stakeholders (n = 7) served as a focus group of advisors to discuss needed supports. Data were analyzed through qualitative descriptive analysis.
Findings
Results revealed themes about challenges and supports needed, and whether supports delivered through digital technology may improve recovery and parenting.
Practice Implications
Future exploration needs to examine the extent to which the use of community‐guided, tailored digital support applications that supplement prescribed treatment can enhance parenting and recovery.
Parental reflective functioning (PRF) is an important predictor of infant attachment, and interventions that target parent–infant/toddler dyads who are experiencing significant problems have the potential to improve PRF. A range of dyadic interventions have been developed over the past two decades, some of which explicitly target PRF as part of their theory of change, and some that do not explicitly target PRF, but that have measured it as an outcome. However, no meta‐analytic review of the impact of these interventions has been carried out to date. The aim of this review was to evaluate the effectiveness of dyadic interventions targeting parents of infant and toddlers, in improving PRF and a number of secondary outcomes. A systematic review and meta‐analysis was conducted in which key electronic databases were searched up to October 2018. Eligible studies were identified and data extracted. Data were synthesised using meta‐analysis and expressed as both effect sizes and risk ratios. Six studies were identified providing a total of 521 participants. The results of six meta‐analyses showed a nonsignificant moderate improvement in PRF in the intervention group (standardised mean difference [SMD]: –0.46; 95% confidence interval [CI] [–0.97, 0.04]) and a significant reduction in disorganised attachment (risk ratio: 0.50; 95% CI [0.27, 0.90]). There was no evidence for intervention effects on attachment security (odds ratio: 0.71; 95% CI [0.19, 2.64]), parent–infant interaction (SMD: –0.10; 95% CI [–0.46, 0.26]), parental depression (SMD: –1.55; 95% CI [–3.74, 0.64]) or parental global distress (SMD: –0.19, 95% CI [–3.04, 22.65]). There were insufficient data to conduct subgroup analysis (i.e. to compare the effectiveness of mentalisation‐based treatment with non‐mentalization‐based treatment interventions). Relational early interventions may have important benefits in improving PRF and reducing the prevalence of attachment disorganisation. The implications for future research are discussed.
Mothers with substance use disorders (SUDs) typically have trauma histories and psychosocial difficulties that lead to poor social-emotional functioning and disrupted mother-child relationships. This 12-month study explored associations of family adverse circumstances and services (case management, therapeutic, and community-based) received by 57-mothers with SUDs and their infants (less than 24-months-old) with changes in social-emotional functioning. All mothers were enrolled in a relationship-based case management program (Parent-Child Assistance Program [PCAP]) that emphasized connecting mothers to appropriate community services. A subset of mothers was additionally provided a trauma-focused psychotherapeutic intervention (infant-parent psychotherapy [IPP]). Dyads in both treatment groups improved in overall social-emotional functioning as assessed by the Functional Emotional Assessment Scale (FEAS). A combined-sample regression analysis revealed that improved FEAS scores were significantly predicted by the number of community services received but not by PCAP case management hours (IPP was not included in this analysis). More adverse circumstances were associated with less improvement in social-emotional functioning in the children; but among the mothers trauma level did not predict FEAS scores. We also found a moderating effect of trauma: Dyads with relatively more adversity showed a significantly greater association of community services received with improvement in FEAS scores than did those with relatively less adversity.
In the context of increasing rates of opioid misuse, particularly by women of childbearing age with histories of trauma, this chapter describes the background, evidence base, conceptual framework, and practice parameters for an attachment-based evidence-informed dyadic intervention utilizing the principles of child-parent psychotherapy with mothers and infants impacted by substance use disorders (SUDs). A strong focus of this chapter is to elaborate on the emotional needs of mothers in early recovery as they enter into the parenting role and on the needs of substance-exposed newborns and their role in fragile infant-parent dyads. A case is presented at the end of the chapter so that readers are better able to conceptualize this novel application of dyadic psychotherapy.
Hintergrund: Reflective Functioning (RF) bedeutet operationalisiertes Mentalisieren. Laut Fonagy, Bateman und Luyten (2015) ist Mentalisieren die Basis für alle wirksamen Psychotherapien. RF kann im Sinne eines Mediators für Therapieerfolg als Wirkmechanismus der Therapie – oder aber als Moderator für Therapieerfolg konzeptualisiert werden. Diese Arbeit gibt zunächst einen Überblick über das Mentalisierungskonzept nach Fonagy, Steele, Steele, Moran und Higgitt (1991). Entwicklungspsychologische, kognitionspsychologische und neuropsychologische Grundlagen werden veranschaulicht.
Ziele: Das Ziel dieses Reviews ist herauszufinden, ob RF in Psychotherapiestudien als Mediator oder als Moderator auf den Therapieerfolg konzeptualisiert werden sollte und welches Modell die überzeugenderen Ergebnisse liefert.
Datenquellen: Die elektronischen Datenbanken PSYNDEX, PsycINFO und Medline wurden durchsucht.
Auswahlkriterien der Studien: Es wurden Psychotherapiestudien, die die mediierende oder moderierende Wirkung RFs auf das Therapieoutcome untersuchen inkludiert.
Teilnehmer und Interventionen: PatientInnen im Alter von 18-65 Jahren mit psychischer Störung nach ICD oder DSM wurden eingeschlossen. Die Interventionen mussten evidenzbasiert und manualisiert sein.
Bewertung der Studien und Synthese der Ergebnisse: Die Daten der Studien wurden systematisch extrahiert und im Kontext der Qualität der jeweiligen Studie interpretiert.
Ergebnisse und Schlussfolgerungen: 18 äußerst heterogen designte Studien wurden gefunden. Davon konzipieren 14 Studien RF als Mediator oder Therapieoutcome und 6 als Moderator oder Prädiktor. Durch die Heterogenität der Studien konnte die Fragestellung nicht eindeutig beantwortet werden. Insgesamt können vier Studien einen signifikant moderierenden Einfluss RFs auf den Therapieerfolg aufzeigen. Nur eine Studie, deren Aussagekraft eingeschränkt ist, kann einen signifikant mediierenden Einfluss RFs auf den Therapieerfolg demonstrieren. Zukünftige Arbeiten, die mit zuverlässigen Designs RF als Mediator für Therapieerfolg konzeptualisieren, sind notwendig.
This research compared two forms of psychodynamic psychotherapeutic interventions for 67 clinically referred infants and their mothers. One was an infant-led psychotherapy delivered through a program called Watch, Wait, and Wonder (WWW). The other was a mother- infant psychotherapy (PPT). Infants ranged in age from 10 to 30 months at the outset of treatment, which took place in weekly sessions over approximately 5 months. A broad range of measures of attachment, qualities of the mother- infant relationship, maternal perception of parenting stress, parenting competence and satisfaction, depression, and infant cognition and emotion regulation were used. The WWW group showed a greater shift toward a more organized or secure attachment relationship and a greater improvement in cognitive development and emotion regulation than infants in the PPT group. Moreover, mothers in the WWW group reported
Substance abuse in pregnant and recently post-partum women is a major public health concern because of effects on the infant and on the ability of the adult to care for the infant. In addition to the negative health effects of teratogenic substances on fetal development, substance use can contribute to difficulties associated with the social and behavioral aspects of parenting. Neural circuits associated with parenting behavior overlap with circuits involved in addiction (e.g., frontal, striatal, and limbic systems) and thus may be co-opted for the craving/reward cycle associated with substance use and abuse and be less available for parenting. The current study investigates the degree to which neural circuits associated with parenting are disrupted in mothers who are substance-using. Specifically, we used functional magnetic resonance imaging to examine the neural response to emotional infant cues (faces and cries) in substance-using compared to non-using mothers. In response to both faces (of varying emotional valence) and cries (of varying distress levels), substance-using mothers evidenced reduced neural activation in regions that have been previously implicated in reward and motivation as well as regions involved in cognitive control. Specifically, in response to faces, substance users showed reduced activation in prefrontal regions, including the dorsolateral and ventromedial prefrontal cortices, as well as visual processing (occipital lobes) and limbic regions (parahippocampus and amygdala). Similarly, in response to infant cries, substance-using mothers showed reduced activation relative to non-using mothers in prefrontal regions, auditory sensory processing regions, insula and limbic regions (parahippocampus and amygdala). These findings suggest that infant stimuli may be less salient for substance-using mothers, and such reduced saliency may impair developing infant-caregiver attachment and the ability of mothers to respond appropriately to their infants.
The authors examined pilot data from an attachment-based parenting intervention for substance-abusing mothers of toddlers (ages 12–36 months). The Mothers and Toddlers Program (MTP) is a 20-week individual therapy intervention that aims to help mothers develop more balanced representations of their children and improve their capacity for reflective functioning (i.e., recognition of the intentional nature of children's behavior). The authors hypothesized that improvement in maternal representational balance and maternal capacity for reflective functioning would correspond with improvements in maternal behavior with toddlers (e.g., sensitivity to cues, responsiveness to distress, and social–emotional growth fostering) and reduction in maternal psychiatric distress and substance abuse. Eight mothers who completed MTP showed moderate improvements in representational balance and reflective functioning, and these changes corresponded with significant improvements in maternal behaviors with toddlers. The authors also compared MTP completers and noncompleters on sociodemographic and psychosocial indexes and examined the validity of the intervention's proposed mechanisms of change. Preliminary findings support the importance of attachment mechanisms and indicate that attachment-based interventions may strengthen substance-abusing mothers' capacities to foster their toddlers' socioemotional development.
In this study we examined three parenting dimensions (involvement, autonomy, and limit-setting) and three potential determinants (maternal addiction, low SES and its correlates, and mothers' perceptions of their children's maladjustment) in order to disentangle features of parenting that are uniquely related to maternal addiction from those related to contextual determinants. We also examined conditional effects of low SES and its correlates on parenting.
Based on a literature review and predictions arising from an ecological model of parenting, we expected that maternal addiction would be related with problems in parental involvement, but that the other parenting dimensions would be related with mothers' perceptions of children's maladjustment and low SES. Accordingly, we examined variance in each parenting dimensions accounted for by each of the three determinants, respectively.
Subjects included 120 (69 opiate-addicted and 51 SES-matched comparison) mothers with children under 16 years of age.
Children's maladaptive behavior was assessed with the Behavioral Assessment System for Children, and parental adjustment with the Parent Child Relationship Inventory.
Direct effect predictions were confirmed and two conditional effects involving single status and family size were also found.
Although many parenting problems have previously been attributed to maternal addiction, only parental involvement is directly related to being an addict; other parenting dimensions may be better explained by contextual factors.
The authors examined 223 children at age 4 years for the effects of prenatal cocaine exposure, exposure to other substances, maternal and environmental risk factors, and neonatal medical problems on IQ, externalizing problems, and internalizing problems. Regression analyses showed that maternal verbal IQ and low environmental risk predicted child IQ. Cocaine exposure negatively predicted children's overall IQ and verbal reasoning scores, but only for boys. Cocaine exposure also predicted poorer short-term memory. Maternal harsh discipline, maternal depressive symptoms, and increased environmental risk predicted externalizing problems. In contrast, only maternal depressive symptoms predicted internalizing problems. These findings indicate that early exposure to substances is largely unrelated to subsequent IQ or adjustment, particularly for girls.
This study examined the prevalence of a history of various combinations of childhood maltreatment types (physical abuse, sexual abuse, and witnessing of maternal battering) among adult members of a health maintenance organization (HMO) and explored the relationship with adult mental health of the combinations of types of childhood maltreatment and emotional abuse in the childhood family environment.
A total of 8,667 adult members of an HMO completed measures of childhood exposure to family dysfunction, which included items on physical and sexual abuse, witnessing of maternal battering, and emotional abuse in the childhood family environment. The adults' current mental health was assessed by using the mental health scale of the Medical Outcomes Study 36-item Short-Form Health Survey.
The prevalences of sexual abuse, physical abuse, and witnessing of maternal violence were 21.6%, 20.6%, and 14.0%, respectively, when the maltreatment types were considered separately. Among respondents reporting any of the maltreatment types, 34.6% reported more than one type of maltreatment. Lower mean mental health scores were associated with higher numbers of abuse categories (mean=78.5, 75.5, 72.8, and 69.9 for respondents with no, one, two, and three abuse types, respectively). Both an emotionally abusive family environment and the interaction of an emotionally abusive family environment with the various maltreatment types had a significant effect on mental health scores.
Childhood physical and sexual abuse, as well as witnessing of maternal battering, were common among the adult members of an HMO in this study. Among those reporting any maltreatment, more than one-third had experienced more than one type of maltreatment. A dose-response relation was found between the number of types of maltreatment reported and mental health scores. In addition, an emotionally abusive family environment accentuated the decrements in mental health scores. Future research examining the effects of childhood maltreatment on adult mental health should include assessments of a wide range of abusive experiences, as well as the family atmosphere in which they occur.
Mothers who are physically and/or psychologically dependent upon alcohol and illicit drugs are at risk for a wide range of parenting deficits beginning when their children are infants and continuing as their children move through school-age and adolescent years. Behavioral parent training programs for drug-dependent mothers have had limited success in improving parent-child relationships or children's psychological adjustment. One reason behavioral parenting programs may have had limited success is the lack of attention to the emotional quality of the parent-child relationship. Research on attachment suggests that the emotional quality of mother-child relationships is an important predictor of children's psychological development through school-age and adolescent years. In this paper, we present a rationale and approach for developing attachment-based parenting interventions for drug-dependent mothers and report preliminary data on the feasibility of offering an attachment-based parenting intervention in an outpatient drug treatment program for women.
This study assessed the effect of cognitive-behavioral therapy on a range of problems associated with complex trauma in a sample of women with comorbid substance use disorders and posttraumatic stress disorder (PTSD).
A total of 107 women with current or subthreshold PTSD and a current substance use disorder from an urban, low-income area were recruited from both community and clinical populations. Participants were recruited between 1997 and 2000. A quasi-experimental design was used, and participants who received cognitive-behavioral therapy (N=75) were compared with those in a control group who received no active study treatment (N=32). All participants were given the same list of community treatment resources and told that they could pursue services while participating in the study if they wished.
At the end of treatment (three months postbaseline), compared with participants in the control group, those in the active treatment group showed significant reductions in symptoms of PTSD and alcohol use disorders, with a trend toward reductions in symptoms of drug use disorders. No significant differences were found between the groups on depression, dissociation, and social and sexual functioning outcomes.
These findings underscore the challenge and necessity of addressing the unique and wide-ranging needs of women with substance use disorder who have been exposed to early and multiple interpersonal traumas.
Using an attachment framework, we examined (1) whether substance-abusing mothers' perceptions of how they were parented were related to the severity of their substance abuse and psychological maladjustment and (2) whether these two factors mediated the association between mothers' perceptions of how they were parented and their children's placement out of home. There were 108 mothers of 248 children who completed interviews upon admission to a methadone maintenance program for women. Measures included lifetime risk composite scores derived from the Addiction Severity Index, the Parental Bonding Instrument, and a demographics questionnaire. A multilevel modeling approach was used to model effects of the hierarchically organized data (e.g., children nested within families). Findings are consistent with an attachment perspective on parenting suggesting that the internal psychological processes of a parent play a critical role in the continuity of parenting.
Data from the Women with Co-occurring Disorders and Histories of Violence Study are used to examine characteristics distinguishing mothers currently providing care for all their minor children (n = 558) from mothers separated from one or more minor children (n = 1396). Mothers are described and compared on background characteristics and experiences, well-being and current functioning, situational context, and services used. Analyses control for number of children, race, and years of education. Mothers separated from children have more children, less education, have more often been homeless, in juvenile detention or jail, and have lower incomes than mothers living with all their children. Mothers separated from children have more extensive experiences of traumatic and stressful life events, and the groups differ in current functioning and patterns of services used. While cross-sectional data do not allow causal inferences, challenges faced by mothers have significant implications for policy and programs.
Maternal substance abuse is the most common factor involved when children come to the attention of the child welfare system. Although there is a clear need for clinical trials to evaluate parenting interventions for drug-dependent women, few studies to date have systematically examined the efficacy of interventions for this population. We first review six published reports of outpatient interventions that aimed to enhance the caregiving skills of substance-abusing mothers caring for children between birth and 5 years of age. After discussing implications of these preliminary studies, we then describe an attachment-based intervention that addresses these implications and has demonstrated preliminary feasibility in a pilot trial.
The purpose of this article is to present a new brief measure for efficiently and effectively identifying children who have been exposed to violence. The tool was derived from an epidemiological survey of children’s experiences completed by parents and was designed to be practical and nonthreatening. The instrument was completed by the parents of 215 children ages six years old and younger. Psychometric evidence indicates satisfactory internal reliability (Cronbach’s alpha = 0.82), and the measure also yields consistent results over time. In addition, it relates appropriately and as expected to another measure of violence and trauma exposure, which indicates validity. While the new measure is still under development, it has implications for use by service providers of young children and their families.
This research compared two forms of psychodynamic psychotherapeutic interventions for 67 clinically referred infants and their mothers. One was an infant-led psychotherapy delivered through a program called Watch, Wait, and Wonder (WWW). The other was a mother–infant psychotherapy (PPT). Infants ranged in age from 10 to 30 months at the outset of treatment, which took place in weekly sessions over approximately 5 months. A broad range of measures of attachment, qualities of the mother–infant relationship, maternal perception of parenting stress, parenting competence and satisfaction, depression, and infant cognition and emotion regulation were used. The WWW group showed a greater shift toward a more organized or secure attachment relationship and a greater improvement in cognitive development and emotion regulation than infants in the PPT group. Moreover, mothers in the WWW group reported a larger increase in parenting satisfaction and competence and decrease in depression compared to mothers receiving PPT. Both WWW and PPT were successful in reducing infant -presenting problems, decreasing parenting stress, and reducing maternal intrusiveness and mother–infant conflict. Some potential reasons for the differential treatment effects and the theoretical, clinical, and methodological implications from the findings are discussed. ©1999 Michigan Association for Infant Mental Health.
This chapter examines the link between substance abuse and parenting from the perspective of behavioral genetics. More specifically, it considers at least three mechanisms by which the intergenerational transmission of drug abuse may operate: genetic transmission, disruption of parenting and family processes, and prenatal drug exposure. It first reviews the literature for each of these mechanisms and their possible interrelatedness, along with the genetic mechanisms underlying the effects of prenatal exposure to drugs on child development. It also explores the genetic and environmental influences on drug use and abuse, factors that may impair an addicted parent’s ability to respond appropriately to his or her child, genetic influences on parenting, and the association between prenatal drug use and child behavior problems. Finally, it discusses a number of novel strategies for separating genetic influences from prenatal exposure to drugs as well as the role of parenting and family environments. A prospective adoption design that integrates the mechanisms of drug abuse transmission is proposed.
This chapter examines the bio-psychosocial characteristics of parenting women with substance use disorders, including family history as well as physical, emotional, and sexual abuse. It considers post-traumatic stress disorder and other psychiatric disorders found in women with substance use disorders, such as depression and anxiety disorders. It also discusses the caregiving environment of pregnant and parenting women with substance use disorders, along with their parenting attitudes.
This chapter examines the impact of parental addiction on child development, including socioemotional development. It first considers the effects of prenatal exposure to drugs and alcohol on fetal development, including birth defects, before turning to a discussion of child developmental outcomes associated with parental addiction during childhood. It then explains how parental addiction increases the risk for early interaction and attachment and affects a child’s cognitive, language, and motor functions as well as the neuropsychological mechanisms controlling attention, memory, visuoperception, and emotion regulation. It also assesses the risk for substance use disorders and other psychiatric disorders and concludes by describing developmentally based interventions for high-risk families aimed at reducing parental drug use and improving child development and parenting quality.
It is not difficult to designate high-risk groups for infants and young children likely to have emotional and social problems in their development. Such groups can be designated according to (a) handicapping and health factors in the child (e. g., prematurity, major sensory motoric deficits, malformations, disfigurements, and multiple hospitalizations); (b) handicapping and health factors in the parent (e. g., major mental illness, such as severe depression, sociopathy, or schizophrenia); and (c) general social and economic factors (e. g., low socioeconomic status, but also including factors such as infants and young children with teenage parents, single parents, and parents with poor marital adjustment) (see Markman & Jones Leonard, Chapter 4). When one is planning intervention, however, designating high-risk groups is an inefficient way of screening. As Frankenburg points out in this volume, there are too many individuals in high-risk groups who do not require intervention— that is, who are not disordered and who are not in the process of becoming disordered. The problem for screening, therefore, is the early identification of those individuals (including those within high-risk groups) who are needing of intervention.
The aim of the study was to determine if spontaneous play was altered in 2-year-olds born to polysubstance-abusing mothers. The study is part of a longitudinal research project of chronic substance-abusing mothers and their children living in poverty in the inner city of Los Angeles, identified in the hospital at birth by positive urine-toxicology screens, and compared to non-substance-abusing mothers and their children living in the same geographic area, of similar ethnic group and socioeconomic and marital status. The behavior of the 31 target and 21 comparison children in the 16-minute procedure was measured by frequency counts of manipulative, functional, and symbolic acts as well as by ratings of the quality of play. The play of the prenatally drug-exposed children differed from the comparison group by demonstrating significantly more immature play strategies, less sustained attention, more deviant behaviors, and fewer positive social interactions with their caregivers.
Opioid medications are among the most effective analgesics. However, the consequences of opioid exposure to the developing human offspring are not known. We assessed whether maternal opioid use in the periconceptional period was associated with the risk of neural tube defects in the offspring.
We used data from 1998 to 2010 from the Slone Epidemiology Center Birth Defects Study, an ongoing case-control study. Mothers were interviewed by telephone within 6 months of delivery about sociodemographic factors and exposures during pregnancy including detailed questions on type and timing of medication use. Mothers of 305 offsprings with neural tube defect were compared with mothers of 7,125 offsprings in the nonmalformed control group and 13,405 offsprings in the malformed control group. Periconceptional opioid use was defined as any reported use in the 2 months after the last menstrual period. Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for study center.
A higher percentage of mothers of offsprings with neural tube defects (3.9%) reported using an opioid medication than mothers of offsprings in the nonmalformed control group (1.6%) and offsprings in the malformed control group (2.0%) with adjusted ORs of 2.2 (95% CI 1.2 -4.2) and 1.9 (95% CI 1.0 -3.4), respectively. When offsprings were restricted to those with spina bifida, the adjusted ORs were 2.5 (95% CI 1.3-5.0) and 2.2 (95% CI 1.1-4.1), respectively.
A 2.2-fold increase in risk would translate to a neural tube defect prevalence of 5.9 per 10,000 live births among women who use opioids. Overall, opioid use in the periconceptional period appeared to be associated with a modest increased risk of neural tube defects. LEVEL OF EVIDENCE:: II.
Sexual assault history is associated with higher risk of problem drinking and drug use in women, yet little is known about mechanisms linking trauma histories in general to women's drinking or drug use problems. This study examined how various types of trauma, substance use coping, and PTSD relate to past-year problem drinking and drug use in women who experienced sexual assault. Data from a large, diverse sample of women who had experienced adult sexual assault were analyzed with structural equation modeling to test a theoretical model of the relationship between trauma types, substance use coping, PTSD symptoms, and past-year drinking and drug use (N=1863). Results show that PTSD symptoms fully mediated the association between non-interpersonal trauma and the use of substances to cope. However, the association between both interpersonal trauma and child sexual abuse severity on substance use to cope was only partially mediated by PTSD symptoms. In turn, use of substances to cope fully mediated the relationship between PTSD and problem drug use as well as partially mediated the effect of PTSD on problem drinking. These results suggest that different trauma types and substance use coping may be important risk factors distinguishing sexually assaulted women who develop PTSD and problematic substance use from those who do not. Identifying women's histories of different traumas may help to identify those at greater risk for substance use problems.
Psychotherapeutic treatments that focus on improving the relational processes between mothers with postpartum depression (PPD) and their infants, as well as the mother's individual therapeutic needs, have a great potential to positively impact the mother, her infant, and their relationship (K.J. Nylen, T.E. Moran, C.L. Franklin, & M. O'Hara, 2006). Utilizing pilot data from an evaluation of a home-based dyadic therapy for mothers with PPD and their infants, this article reports on a recent academic-community partnership study. The effectiveness of the intervention was examined, specifically regarding changes in mother's mood, parenting experience, and relationship with her infant. In addition, associations were examined among maternal self-report variables measuring change from pre- to posttreatment in PPD, psychological distress, and maternal perceptions of parenting and those variables measuring change in observer ratings of maternal-infant interactions. Results showed improvements in mothers' depression, distress, and perceptions of parenting as well as many ratings of mothers' interactions with their infants. However, only improvements in maternal perceptions of parenting, such as maternal self-esteem and parenting stress, were associated with better mother--infant interactions. Importance of this research for the field of infant mental health as well as clinical implications are discussed.
The specialized needs of pregnant and parenting women in the treatment of drug addiction must not be underestimated. The impact of substance abuse on developmental outcomes for young infants and children supports the notion that attention to the parent–child relationship is a critical aspect of addiction treatment for this population. As such, the standard of care appears to be shifting from separating mothers and young children while the mother completes addiction treatment to women residing with their children while in treatment and receiving concurrent addiction treatment and parenting education. While parenting education is important, it may not provide the needed relationship intervention to address the myriad of issues often present for female recovering addicts and their children. This article describes the evolution and workings of a program for integrating infant mental health practice into a long-term residential treatment community for pregnant and parenting women with addiction. The principles and structure of the modified therapeutic community are described, as are the ways in which infant mental health practice have been effectively integrated and incorporated into the addiction treatment philosophy. A case example is provided, and clinical implications are discussed.
The early identification of social and emotional problems in infants, toddlers, and young children is critical for improving developmental outcomes. The Ages and Stages Questionnaires: Social-Emotional, a newly-developed screening tool, is described in this article. Questionnaires span the 3- to 63-month period with 8 separate assessment intervals. Research findings, including data on 3014 questionnaires, are reported. Internal consistency was generally high, with an overall alpha of 0.82. Test-retest reliability between parents’ classifications was 0.94. Sensitivity ranged from 0.75 to 0.89 with 0.82 overall sensitivity; specificity ranged from 0.82 to 0.96 with 0.92 overall specificity. Parents reported easy understanding and high satisfaction with the questionnaires.
This study investigated association between post-traumatic stress disorder (PTSD) and a 1-year follow-up heroin use among female clients in methadone clinics in Israel. Participants were 104 Israeli female clients from four methadone clinics (Mean age = 39.09, SD = 8.61) who reported victimization to childhood sexual abuse. We tested traces in urine of these female clients for heroin a year preceding and a year following the assessment of their PTSD. Results show that 54.2% reported symptoms that accedes the DSM-IV criteria for PTSD. We found that among childhood victimized women PTSD is associated with more frequent use of heroin at a 1-year follow-up even after controlling for duration of the stay at the clinic, background, other traumatic experiences and heroin use a year prior the assessment of their PTSD. This study shows the potential long-run negative consequences of childhood sexual abuse. Not only are these sexually abused women trapped into drug dependence and addiction, they cannot break the vicious cycle of continuing the use of illicit drugs even when treated for their addiction. One major practice implication is that treatment for PTSD proven efficacious will be provided in the methadone and other drug treatment services.
Substance abuse during early motherhood has become a significant problem and has led to accelerated efforts to develop specific treatment facilities for these mothers and children. Despite the often intensive treatment efforts in residential settings, there is surprisingly little evidence of their efficacy for enhancing the quality of caregiving. The situation of these mother-child pairs is exceptionally complex and multilevel, and has to be taken into account in the content and structuring of treatment. Intensive work in the "here and now" focusing on the mother-child relationship from pregnancy onwards in an effort to enhance maternal reflective capacity and mindedness is considered a key element for better treatment prognosis, in terms of both abstinence and quality of parenting. Pioneering work with such a focus is described in this article.
This study describes the prevalence of childhood traumatic events (CTEs) among adults with comorbid substance use disorders (SUDs) and mental health problems (MHPs) and assesses the relation between cumulative CTEs and adult health outcomes. Adults with SUDs/MHPs (N=402) were recruited from residential treatment programs and interviewed at treatment admission. Exposures to 9 types of adverse childhood experiences were summed and categorized into 6 ordinal levels of exposure. Descriptive analyses were conducted to assess the prevalence and range of exposure to CTEs in comparison with a sample from primary health care. Logistic regression analyses were conducted to examine the association between the cumulative exposure to CTEs and adverse health outcomes. Most of the sample reported exposure to CTEs, with higher exposure rates among the study sample compared with the primary health care sample. Greater exposure to CTEs significantly increased the odds of several adverse adult outcomes, including PTSD, alcohol dependence, injection drug use, tobacco use, sex work, medical problems, and poor quality of life. Study findings support the importance of early prevention and intervention and provision of trauma treatment for individuals with SUDs/MHPs.
An account is given of attachment theory as a way of conceptualizing the propensity of human beings to make strong affectional bonds to particular others and of explaining the many forms of emotional distress and personality disturbance, including anxiety, anger, depression and emotional detachment, to which unwilling separation and loss give rise. Though it incorporates much psychoanalytic thinking, many of its principles derive from ethology, cognitive psychology and control theory. It conforms to the ordinary criteria of a scientific discipline.
Certain common patterns of personality development, both healthy and pathological, are described in these terms, and also some of the common patterns of parenting that contribute to them.
This paper reports the community prevalence of 20 life traumas and considers their individual relevance as risk factors for psychiatric disorder. Also presented is the first evidence on the mental health significance of cumulative adversity as indexed by a count of lifetime exposure to a wide array of potentially traumatic events. The question of the importance of considering such events within efforts to assess variations in life stress is also examined. Our results demonstrate clear relationships between many traumatic events and, especially, accumulated lifetime trauma experience and both psychological distress and psychiatric disorder. That these relationships persist with temporal priority controlled - and net of the effects of parental psychopathology - suggest the causal relevance of major lifetime events and the conclusion that they represent on important dimension of increased mental health risk. From these findings and from evidence for the significance of traumas in disorder recurrence, it is contended that failure to take account of such events has resulted in the systematic underestimation of the role of stress exposure in accounting for variations in emotional distress and disorder.
Ten mother-infant dyads in which the mother abused drugs during pregnancy were compared to 10 matched drug-free dyads using a short form of the Parent-Child Early Relational Assessment to analyze videotaped mother-infant interactions. Interactions consisted of two five-minute segments: structured and unstructured play. Infants were 8-12 months of age. There was a consistent tendency for the drug abusing group mean scores to separate from the controls. Drug abusing dyads had significantly more (r = .71, Fisher's Exact Probability) ratings below 3.0 in the unstructured play situation for items that measured enthusiasm, responsivity to infant cues, and infant happiness. These categories provide preliminary evidence for those characteristics which may be most problematic in the relationship between drug abusing mothers and their infants, especially in situations in which mother is responsible for providing structure.
This paper explores the parenting of drug-dependent women and the contributions of comorbid psychopathology to their parenting. A sample of 32 children whose mothers were dependent on opioid drugs during pregnancy and 37 children whose mothers were not drug users were followed from birth to middle childhood. Multivariate regression analyses were conducted contrasting whether maternal substance abuse or psychopathology was more closely linked to parenting behaviors and continuity in parenting over time. Maternal drug dependence was related to whether mothers were able to remain primary caregivers for their children over time, even after controlling for psychopathology. Maternal drug use was related to unresponsive and negative parenting behavior during mother-infant interaction, but this relation was largely accounted for by the effects of comorbid maternal psychopathology on parenting, particularly symptoms of antisocial and related personality disorders. For those children whose mothers continued to care for them into middle childhood, perceptions of their mothers as rejecting were related to maternal antisocial personality and maternal depression. Substance-abuse treatment for women should be integrated with interventions addressing their mental health and parenting needs.
Children with in utero cocaine exposure may be at risk for adverse neurodevelopmental outcome. To evaluate such outcome in young children, we administered the Battelle Developmental Inventory (BDI) to a group of inner-city children with (COC) and without (CON) in utero cocaine exposure at ages 3 and 5 years. Sixty-five COC and 68 CON, similar at age of testing, were evaluated at both time points by examiners masked to child group status. Both groups scored poorly and worsened over time. Although Total BDI raw scores were lower in the COC group than in the CON group at 3 years, this difference was related to postnatal environmental factors, caregiver (p = .022), and home environment (p = .010), not to in utero cocaine exposure (p = .88). At 5 years, the Total BDI score was related to the home environment (p < .001) but not to the caregiver (p = .36) or in utero cocaine exposure (p = .83). We conclude that inner-city children are at risk for adverse developmental outcome regardless of in utero cocaine exposure.
To determine the impact of parental substance abuse on children, the cognitive skills and behavior ratings of 268 school-age children placed in family foster care were examined. As a group, the children in family foster care presented with low average cognitive skills and made significant improvement in cognitive functioning during placement. The children with prenatal exposure to drugs scored significantly lower in cognitive skills at the beginning of placement but made significantly more progress than the other children during placement. Behavior ratings by the foster parents and teachers revealed that 29% of the children had scores in the significant range, and the children exposed prenatally to drugs had a higher incidence of behavior problems at school compared to family foster care peers. Recommendations for further study of these factors and for enhancing outcomes for children in care are provided.
The relation between caregiver intrusiveness and the quality of attachment was tested among 51 prenatally drug-exposed toddlers and their primary caregivers. Biological mothers and kinship/foster caregivers neither differed as to caregiver intrusiveness nor as to their toddlers' attachment security and attachment organization. Insecure and disorganized/disoriented attachments were found to be more prevalent in this sample than in normal samples. In keeping with recent findings in non-drug-abusing samples (Isabella & Belsky, 1991; Lyons-Ruth, Repacholi, McLeod, & Silva, 1991), more caregivers of toddlers with avoidant or disorganized/disoriented attachments were found to be intrusive than caregivers of toddlers with secure or resistant attachments.
This study examined differences in substance abuse severity, trauma history, posttraumatic stress disorder (PTSD) symptomatology and psychiatric comorbidity among treatment-seeking women (N= 74) with PTSD and either comorbid cocaine or alcohol dependence. Women in the cocaine/PTSD group, compared with the alcohol/PTSD group, demonstrated greater occupational impairment (e.g., greater severity on the employment subscale of the Addiction Severity Index, less monthly income, fewer days worked in past month), more legal problems (e.g., greater number of months incarcerated and arrests for prostitution), and greater social impairment (e.g., fewer number of close friends, less likely to be married). Women in the alcohol/PTSD group evidenced higher rates of exposure to serious accidents, other situations involving serious injury, and other extraordinarily stressful life events. Rates of major depression and social phobia were higher among the alcohol/PTSD group than the cocaine/PTSD group. Women in the alcohol/PTSD group scored higher on the CAPS avoidance, hyperarousal, and total subscale scores. The current findings enhance our understanding of the substance-specific profiles of women with PTSD and comorbid substance use disorders and may have important implications for the design of dual-diagnosis interventions.
To assess the relationship between cumulative environmental risks and early intervention, parenting attitudes, potential for child abuse and child development in substance abusing mothers.
We studied 161 substance-abusing women, from a randomized longitudinal study of a home based early intervention, who had custody of their children through 18 months. The intervention group received weekly home visits in the first 6 months and biweekly visits from 6 to 18 months. Parenting stress and child abuse potential were assessed at 6 and 18 months postpartum. Children's mental and motor development (Bayley MDI and PDI) and language development (REEL) were assessed at 6, 12, and 18 months postpartum. Ten maternal risk factors were assessed: maternal depression, domestic violence, nondomestic violence, family size, incarceration, no significant other in home, negative life events, psychiatric problems, homelessness, and severity of drug use. Level of risk was recoded into four categories (2 or less, 3, 4, and 5 or more), which had adequate cell sizes for repeated measures analysis.
Repeated measures analyses were run to examine how level of risk and group (intervention or control) were related to parenting stress, child abuse potential, and children's mental, motor and language development over time.
Parenting stress and child abuse potential were higher for women with five risks or more compared with women who had four or fewer risks; children's mental, motor, and language development were not related to level of risk. Children in the intervention group had significantly higher scores on the PDI at 6 and 18 months (107.4 vs. 103.6 and 101.1 vs. 97.2) and had marginally better scores on the MDI at 6 and 12 months (107.7 vs. 104.2 and 103.6 vs. 100.1), compared to the control group.
Compared to drug-abusing women with fewer than five risks, women with five or more risks found parenting more stressful and indicated greater inclination towards abusive and neglectful behavior, placing their infants at increased risk for poor parenting, abuse and neglect. Early home-based intervention in high-risk families may be beneficial to infant development.
One hundred and five drug-dependent women in outpatient perinatal addiction treatment were classified by cluster analysis of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profiles into high and low psychopathology (HP and LP) groups that differed on three validation measures. The HP group (n=29, 27.6%) had elevations on MMPI-2 Scales F, 2, 4, 6, 7, and 8, while the LP group (n=76, 72.4%) generated a normal range profile with elevations on Scales F and 4. Psychological outcomes differed by group. HP participants showed reduced alcohol, family, and psychiatric severity, and reduced depressive symptoms, while LP subjects showed reduced drug, self-debasing, and acting-out problems. Data suggest the need for lower intensity services for the majority of the perinatal drug dependent population with LP.
Reflective functioning refers to the essential human capacity to understand behavior in light of underlying mental states and intentions. The construct, introduced by Fonagy, Steele, Steele, Moran, and Higgitt in 19915.
Fonagy , P. ,
Steele , M. ,
Moran , G. ,
Steele , H. and
Higgitt , A. 1991. The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 13: 200–216. View all references, and elaborated by Fonagy and his colleagues over the course of the next decade, has had an enormous impact on developmental theory and clinical practice. This paper introduces the construct of parental reflective functioning, which refers to the parent's capacity to hold the child's mental states in mind, and begins with a review of Fonagy and his colleagues' essential ideas regarding the reflective function. Next, the applicability of this construct to parental representations of the child and the parent – child relationship is considered. A system for coding parental reflective functioning, which will serve as the organizing framework for this special issue, is described. Finally, the three papers that make up this special section are introduced.
The acknowledgment of the existence of age-specific posttraumatic stress symptoms in infants, toddlers, and preschoolers points to the urgent need for standardized assessment tools for violence exposure and trauma symptoms in young children. The authors review the assessment measures currently available for the evaluation of potentially traumatic events (PTE) and posttraumatic stress disorder (PTSD) symptoms in children less than 6 years old. Each measure is described and its strengths and weaknesses discussed in a developmental context, while also considering the specific difficulties inherent to the assessment of young children. Recommendations for further test development are given.
Mental health disorders, substance use, and domestic violence often occur together. However, studies examining the impact of these conditions in mothers on the well-being of their children have focused only on isolated conditions.
To examine the cumulative effect of maternal mental health disorders, substance use, and domestic violence on the risk of behavior problems in young children.
A birth cohort (1998-2000) followed up to age 3 years.
Eighteen large US cities.
At 3 years, 2756 (65%) were followed up from the population-based birth cohort of 4242. Thirty-six percent had annual incomes below the poverty threshold.
One year after delivery, mothers were asked questions about conditions in 3 categories: (1) mental health (major depressive episode and generalized anxiety disorder), (2) substance use (smoking, binge drinking, and illicit drug use), and (3) domestic violence (emotional and physical). At 3 years, mothers completed questions from the Child Behavior Checklist.
Fifty percent of mothers had a condition in at least 1 of the 3 categories. The prevalence of child behavior problems increased with the number of categories (0, 1, 2, or 3) in which the mother reported a condition: respectively, 7%, 12%, 17%, and 19% for aggression (P<.001); 9%, 14%, 16%, and 27% for anxious/depressed (P<.001); and 7%, 12%, 15%, and 19% for inattention/hyperactivity (P<.001). This graded risk persisted after adjustment for sociodemographic and prenatal factors and for paternal mental health and substance use.
The risk of child behavior problems increased with the number of areas--mental health, substance use, or domestic violence--in which the mother reported difficulties. Preventing behavior problems in young children requires family-oriented strategies that address the needs of both parents and their children.
The goal was to determine how violence exposure affects the relationship between maternal depression, cognitive ability, and child behavior.
A multivariate regression analysis of data for a nationally representative sample of kindergarten students was performed. Maternal depression and violence exposure were measured with standardized parent interviews. Standardized T scores were derived from direct testing of children in reading, mathematics, and general knowledge; child behavior was reported by teachers.
A total of 9360 children had neither maternal depression nor violence exposure, 779 violence only, 1564 depression only, and 380 both. Maternal depression alone was associated with poorer mean T scores for reading, mathematics, and general knowledge. However, this effect was attenuated by nearly 25% for reading and general knowledge with adjustment for violence. Children with concurrent exposure to depression and violence had lower mean T scores for reading, mathematics, and general knowledge, as well as more-concerning behaviors, than did those exposed to either factor alone. Across all outcome measures, boys seemed more affected than girls.
Violence compounds the effect of maternal depression on school functioning and behavior. Research and intervention planning for children affected by maternal depression should consider violence exposure.
Patterns of attachment
- M D Ainsworth
- M C Blehar
- E Waters
- S Wall
Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Earlbaum.