Parenting stress: A novel mechanism of addiction vulnerability

Neural correlates of altered emotional responsivity to infant stimuli in mothers who use substances

Mothers who use substances during pregnancy and postpartum may have altered maternal behavior towards their infants, which can have negative consequences on infant social-emotional development. Since maternal substance use has been associated with difficulties in recognizing and responding to infant emotional expressions, investigating mothers' subjective responses to emotional infant stimuli may provide insight into the neural and psychological processes underlying these differences in maternal behavior. In this study, 39 mothers who used substances during the perinatal period and 42 mothers who did not underwent functional magnetic resonance imaging while viewing infant faces and hearing infant cries. Afterwards, they rated the emotional intensity they thought each infant felt ('think'-rating), and how intensely they felt in response to each infant stimulus ('feel'-rating). Mothers who used substances had lower 'feel'-ratings of infant stimuli compared to mothers who did not. Brain regions implicated in affective processing (e.g., insula, inferior frontal gyrus) were less active in response to infant stimuli, and activity in these brain regions statistically predicted maternal substance-use status. Interestingly, 'think'-ratings and activation in brain regions related to cognitive processing (e.g., medial prefrontal cortex) were comparable between the two groups of mothers. Taken together, these results suggest specific neural and psychological processes related to emotional responsivity to infant stimuli may reflect differences in maternal affective processing and may contribute to differences in maternal behavior in mothers who use substances compared to mothers who do not. The findings suggest potential neural targets for increasing maternal emotional responsivity and improving child outcomes.

Early developmental risks for tobacco addiction: A probabilistic epigenesis framework

Considerable progress has been made in elucidating the relationships between early life psychobiological and environmental risk factors and the development of tobacco addiction. However, a comprehensive understanding of the heterogeneity in tobacco addiction phenotypes requires integrating research findings. The probabilistic epigenesis meta-theory offers a valuable framework for this integration, considering systemic, multilevel, developmental, and evolutionary perspectives. In this paper, we critically review relevant research on early developmental risks associated with tobacco addiction and highlight the integrative heuristic value of the probabilistic epigenesis framework for this research. For this, we propose a four-level systems approach as an initial step towards integration, analyzing complex interactions among different levels of influence. Additionally, we explore a coaction approach to examine key interactions between early risk factors. Moreover, we introduce developmental pathways to understand interindividual differences in tobacco addiction risk during development. This integrative approach holds promise for advancing our understanding of tobacco addiction etiology and informing potentially effective intervention strategies.

Early Insights into Implementation of Universal Screening, Brief Intervention, and Referral to Treatment for Perinatal Substance Use

OBJECTIVES

Perinatal substance use is a growing concern across the United States. Universal screening, brief intervention, and referral to treatment (SBIRT) is one systems-level approach to addressing perinatal substance use. The objective of this study is to assess early efforts to implement SBIRT in an outpatient obstetric clinic.

METHODS

The research team implemented universal screening with the 5 P's screening tool. Providers then engaged patients in a brief intervention and referred to a care manager who then worked with patients via tele-health to connect patients with needed services. Feasibility was measured through the collection of aggregate data describing frequency of universal screening and referral to treatment. The implementation team met bi-weekly to reflect on implementation barriers and facilitators.

RESULTS

In the first year of implementation, 48.5% of patients receiving care in the clinic completed the 5 P's screener at least once during the perinatal period. Screening occurred in a little over a quarter (26.5%) of eligible visits. Of the 463 patients that completed the 5 P's at least once during the perinatal period, 195 (42%) unique patients screened positive (answered yes to at least one question).

CONCLUSIONS FOR PRACTICE

Early implementation efforts suggest this approach is feasible in this obstetric setting. Similar implementation studies should consider implementing universal screening for substance use and perinatal mood and anxiety disorders simultaneously; guide efforts using an implementation framework; invest resources in more intensive training and ongoing coaching for providers; and adopt strategies to track frequency and fidelity of brief intervention.

Effects of Parent-Child Sandplay Therapy for preschool children with autism spectrum disorder and their mothers: A randomized controlled trial

PURPOSE

To evaluate the effects of the Parent-Child Sandplay Therapy (PCST) Program on autism behaviors, social responsiveness and sleep quality among preschool children with autism spectrum disorder (ASD), and their mothers' parenting stress.

DESIGN AND METHODS

A prospective, randomized controlled, parallel-group trial was employed. Fifty-two child-mother dyads were randomly assigned to an intervention group (n = 26) or a control group (n = 26) from February 2017 to February 2019. The intervention group was treated with a 20-week PCST Program plus an Applied Behavior Analysis-based program (ABA-based program), whereas the control group received only the ABA-based program. Outcome measures included the Autism Behavior Checklist total scores, Social Responsiveness Scale scores, Children's Sleep Habits Questionnaire scores, and Parenting Stress Index-Short Form scores, measured at baseline, post-intervention (20 weeks after baseline) and follow-up assessments (32 weeks after baseline).

RESULTS

Finally, 43 dyads completed the study. The linear mixed model analysis resulted in a significant group*time interaction effect of ABC score (Est = 2.027, t = 3.277; p < 0.01), SRS score (Est = 3.377, t = 6.095; p < 0.01), PSI-SF score (Est = 3.873, t = 4.253, p < 0.01), and CSHQ score (Est = 3.158, t = 6.485; p < 0.05).

CONCLUSION

Our findings suggested that the PCST Program could potentially improve social interaction and sleep quality of preschool children with ASD while decreasing parenting stress.

PRACTICE IMPLICATIONS

The PCST Program was found to be a feasible and a promising treatment for children with mild-to-moderate ASD as well as for their parents. It was a nurse-led program, which could be integrated into the usual nursing care of children with autism spectrum disorder in special education schools.

TRIAL REGISTRATION

Chinese Clinical Trials Registry, ChiCTR2100047699.

Mothering from the Inside Out: Results of a community-based randomized efficacy trial testing a mentalization-based parenting intervention for mothers with addictions

Mothering from the Inside Out (MIO) is a mentalization-based parenting intervention developed to address challenges common among mothers experiencing substance use disorders (SUDs) and previously deemed effective when delivered by research clinicians. This randomized clinical trial was designed to test the efficacy of MIO when delivered by community-based addiction counselors in Connecticut, USA. Ninety-four mothers [M(SD)age = 31.01(4.01) years; 75.53% White] caring for a child 11-60 months of age were randomly assigned to participate in 12 sessions of either MIO or psychoeducation. Caregiving, psychiatric, and substance use outcomes were assessed repeatedly from baseline through 12-week follow-up. Mothers who participated in MIO showed decreased certainty about their child's mental states, and decreased depression; their children demonstrated increased clarity of cues. Participation in MIO was not associated with the same degree of improvement that was observed in prior trials where MIO was delivered by research clinicians. However, when delivered by community-based clinicians, MIO may be protective against a deterioration in caregiving over time often seen in mothers with addictions. The drop in efficacy of MIO in this trial raises questions about intervention-intervenor fit. Research should examine factors influencing MIO effectiveness to close the science-to-service gap common in the dissemination of empirically validated interventions.

Cumulative Risk for Children's Behavior Problems and Child Abuse Potential among Mothers Receiving Substance Use Treatment: The Unique Role of Parenting Stress

There is a high prevalence of children whose parents suffer with a substance use disorder (SUD), which is associated with negative outcomes for children such as behavior problems and parents' child abuse potential. To understand negative consequences for children, it is important to consider a cumulative risk model, examining the impact of multiple co-occurring risks, as well as examine unique singular risk factors, such as parenting stress, which may have a direct effect on outcomes as well as mediate an association between cumulative risk and outcomes. Data came from 99 mothers with SUD, engaged in a substance treatment program. Results found support for a cumulative risk model for child behavior problems and parents' child abuse potential, without the inclusion of parenting stress. However, parenting stress partially and fully mediated the relation between cumulative risk and child behavior problems and cumulative risk and parent child abuse potential, respectively. Results suggest the importance of intervention programs targeting parenting stress, to help reduce child behavior problems and parents' child abuse potential, among parents with high levels of risk and SUD.

Factor structure of the Parenting Stress Index-Short Form used in the Japan Environment and Children's Study

The Parenting Stress Index-Short Form (PSI-SF) has been widely employed to assess parenting stress in a number of research and clinical trials. To date, no parenting stress studies in Japan have examined the factor structure, validity, and reliability of the PSI-SF. Therefore, this study aimed to evaluate the psychometric properties of this 19-item version as administered in a national cohort study, the Japan Environment and Children's Study, to two sample groups of mothers, those with a 1.5-year-old child and those with a 2.5-year-old child (n = 79,282 and 75,831, respectively). We performed exploratory factor analysis to re-examine the appropriate factor structure, confirmatory factor analysis to evaluate goodness of fit, and calculated Cronbach's α and Pearson's r coefficients to evaluate internal consistency and reproducibility over time, respectively. The results highlighted that a three-factor structure fit the instrument better than a two-factor structure, yielding better scores for the model fit indices and the α and r coefficients. In addition, the third factor identified in this study was strongly associated with having a relationship with and help from the husband. The findings suggest the importance of using a parenting stress scale with various factors to evaluate mothers' parenting stress.

Parenting and psychosis: An experience sampling methodology study investigating the inter-relationship between stress from parenting and positive psychotic symptoms

OBJECTIVES

There is a strong association between stress and psychotic symptoms, and this study examined the bidirectional nature of this relationship in parents with psychosis, with negative affect as a mediator and a range of other psychosocial factors included as covariates. It also examined whether stress from parenting had a larger impact on psychosis than non-parenting stress.

DESIGN

The study used a within-participants repeated measures design, using experience sampling methodology (ESM). ESM is a self-report surveying technique completed over an intensive longitudinal period. Participants completed six surveys a day, for 10 days.

METHODS

Thirty-five participants with psychosis who were a parent to a child between the ages of 2 and 16 took part. Study phones alerted participants to complete surveys by beeping at semi-random intervals over 10 days. Multi-level modelling was used with surveys at Level-1 and participants at Level-2. Predictor variables were time-lagged in order to infer directionality.

RESULTS

Parenting stress was found to predict psychotic symptoms, and this relationship was mediated by negative affect. The reverse direction was also confirmed. Few of the additional psychosocial factors were found to have a significant impact on the models' estimations. Parenting stress was not found to have a larger impact on psychosis than other sources of stress.

CONCLUSIONS

This study provides further evidence of the bidirectional relationship between stress and psychosis in the context of parenting. Further research should explore if parenting stress plays a unique role in predicting psychotic symptoms by comparing parents and non-parents with psychosis.

Reflective functioning in mothers with addictions: Differential relationships involving family history of mental illness and substance use

Parental reflective functioning (RF) is often cited as an important domain in which mothers with addictions struggle in their roles as parents, though the links between addiction and RF remain unclear. Exposure to attachment trauma associated with parental mental illness and substance use is commonly associated with both addiction and lower RF. We thus examined how family history of parental mental illness and substance use may relate to the RF of mothers with addictions. One hundred ninety-four mothers in outpatient substance use treatment completed the Parent Development Interview and provided information about whether their mothers and fathers experienced mental illness or problems with substance use. Univariate ANOVAs revealed an interaction between family history of maternal mental illness and maternal substance use. Among mothers with a history of maternal substance use, those with a history of maternal mental illness had higher RF than those who had no history of maternal mental illness. Among mothers who did not report a family history of maternal mental illness, mothers who had a family history of maternal substance use exhibited significantly lower RF than mothers with no family history of maternal substance use. Exposure to paternal mental illness or substance use was not associated with mothers’ RF. These findings highlight the importance of disentangling the contributions of attachment trauma to mothers’ RF and utilizing interventions that support mothers’ capacity to reflect about how their early experiences of being cared for by a mother with a mental illness or addiction may impact their current caregiving behaviors.

The effectiveness of psychosocial interventions at reducing the frequency of alcohol and drug use in parents: findings of a Cochrane Review and meta-analyses

BACKGROUND AND AIM

Parental substance use is a major public health and safeguarding concern. There have been a number of trials examining interventions targeting this risk factor. We aimed to estimate the effectiveness of psychosocial interventions at reducing parental substance use.

DESIGN

We used systematic methods to identify trials; pooling data using a random-effects model. Moderator analyses examined influence of parent gender, presence of child in treatment and intervention type.

SETTING

No restrictions on setting.

PARTICIPANTS

Substance using parents of children below the age of 21 years.

INTERVENTIONS

Psychosocial interventions including those that targeted drug and alcohol use only, and drug and alcohol use in combination with associated issues.

MEASUREMENTS

Frequency of alcohol use and frequency of drug use.

FINDINGS

We included eight unique studies with a total of 703 participants. Psychosocial interventions were more effective at reducing the frequency of parental alcohol use than comparison conditions at 6-month [standardized mean difference (SMD) = - 0.32, 95% confidence interval (CI) = -0.51 to -0.13, P = 0.001] and 12-month follow-up (SMD = -0.25, 95% CI = -0.47 to -0.03, P = 0.02) and frequency of parental drug use at 12 months only (SMD = -0.21, 95% CI = -0.41 to -0.01, P = 0.04). Integrated interventions which combined both parenting and substance use targeted components were effective at reducing the frequency of alcohol use (6 months: SMD = -0.56, 95% CI = -0.96 to -0.016, P = 0.006; 12 months: SMD = -0.42, 95% CI = -0.82 to -0.03, P = 0.04) and drug use (6 months: SMD = -0.39, 95% CI = -0.75 to -0.03, P = 0.04; 12 months: SMD = -0.43, 95% CI = -0.80 to -0.07, P = 0.02). Interventions targeting only substance use or parenting skills were not effective at reducing frequency of alcohol or drug use at either time-point.

CONCLUSION

Psychosocial interventions should target both parenting and substance use in an integrated intervention.

An intergenerational lifespan perspective on the neuroscience of prenatal substance exposure

Prenatal substance exposure has the potential to impact a variety of domains, with neurobiological effects that last throughout the lifespan. Different substances may impact the brain in both specific and diffuse ways; however, the aberrant neural outcomes following exposure tend to coalesce in three areas: (1) sensorimotor development; (2) arousal, motivation, and reward; and (3) executive functioning, impulse control, and emotion regulation. This manuscript represents a summary and update of a previous review (Morie et al., 2019). We organize this piece by domain and summarize data from published neuroimaging studies that examine the neural correlates of prenatal exposure across developmental stages. While the published neuroimaging literature in the area of prenatal exposure has a range of sampling concerns that may limit generalizability as well as longitudinal prediction, the findings to date do point to domains of interest warranting further study. With this caveat, we synthesize the extant findings to describe ways in which prenatal substance exposure is associated with developmental psychopathology and implicated in potentially aberrant behavioral patterns beginning in infancy and persisting through childhood, adolescence, adulthood, and even parenthood. We also examine how substance abuse may impact parenting behaviors that in turn influences infant and child behavior in ways that may be additive or obscure the direct teratological effects of prenatal exposure. Given this observation, we offer an additional intergenerational lens through which prenatal substance exposure should be studied.

Prenatal Reflective Functioning as a Predictor of Substance-Using Mothers' Treatment Outcome: Comparing Results From Two Different RF Measures

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.

Kurzzeiteffekte und Akzeptanz einer Intervention für drogenabhängige Eltern: Das „SHIFT PLUS“ Elterntraining

Hintergrund Eltern mit einer Drogenabhängigkeit sind häufig in ihren elterlichen Kompetenzen eingeschränkt. Die Lebenswelt von Kindern, die in suchtbelasteten Familien aufwachsen, ist oft prekär, insbesondere wenn diese von der Drogensubkultur geprägt ist. Gleichzeitig stehen für Mütter und Väter mit Drogenproblemen in Deutschland keine evidenzbasierten, standardisierten Interventionen zur Verfügung.

Methode Mit SHIFT PLUS wurde ein modularisiertes Gruppenprogramm für drogenabhängige Eltern mit Kindern bis 8 Jahren entwickelt, welches ihre Elternkompetenzen und die Familienresilienz stärken sowie ihre Bereitschaft bzw. Fähigkeit zur Abstinenz fördern soll. Das Training basiert auf dem bestehenden „SHIFT“-Elterntraining für Crystal Meth-konsumierende Eltern und wurde für den gesamten Bereich der Abhängigkeit von illegalen Substanzen erweitert sowie um Module für Angehörige ergänzt. Die Umsetzung des Programms erfolgte an acht Praxisstandorten im Bundesgebiet in Kooperation von Sucht- und Jugendhilfeeinrichtungen mit N=87 teilnehmenden Eltern. Zur Evaluation der kurzzeitigen Wirkeffekte wurde ein quasi-experimentelles Forschungsdesign mit Interventions- und Wartekontrollgruppe zu zwei Messzeitpunkten realisiert. Ergänzend wurden Akzeptanz und Praktikabilität durch Teilnehmende und Trainer/innen bewertet.

Ergebnisse Das SHIFT PLUS-Elterntraining zeigte sich als praktikabel und hoch akzeptiert von teilnehmenden Müttern und Vätern, die berichteten familiäre Herausforderungen subjektiv besser bewältigen zu können. Die Wirksamkeitsevaluation zeigte zudem eine signifikante Reduktion depressiver Symptome in der IG sowie einen signifikant besseren Umgang mit dem Thema Sucht in der Familie. Ergänzend verbesserten sich beide Gruppen hinsichtlich psychischer Belastungen, Substanzkonsum und Elternkompetenz.

Schlussfolgerung Die Intervention bietet eine innovative Ergänzung zur evidenzbasierten Unterstützung suchtbelasteter Familien in Deutschland. Sie ermöglicht eine systematische Förderung elterlicher Fähigkeiten und familiärer Resilienz unter Berücksichtigung einer kooperativen Versorgung durch Jugend- und Suchthilfe. Der direkte Einbezug von Angehörigen in das Training gestattet dieser Zielgruppe zudem einen direkten, niedrigschwelligen Zugang zum Hilfesystem.

Maternal Parenting Stress, Disengagement Strategies for Managing Parenting Stress, and Hazardous Alcohol Use among Mothers of Adolescents

Objective: According to the reward- stress dysregulation model of addiction and parenting, parenting stress may play a critical role in the etiology and maintenance of substance misuse. To date, limited work has examined how parenting stress may relate to hazardous alcohol use among mothers of adolescents. The present study examined if parenting stress interacted with maternal stress responses (i.e., disengagement coping, involuntary disengagement stress responses) in relation to maternal hazardous alcohol use. Method: Two hundred and fifty-three mothers (n = 147 hazardous alcohol users; 58% of the sample) of adolescents between the ages of 12 and 16 years participated in the current study. Mothers were recruited using Qualtrics panel services. Mothers reported on their parenting stress, strategies for managing parenting stress, and use of alcohol. Mothers also reported basic demographic information (Mage = 41.10 years, 86.6% identified as white, 81.1% of mothers were married). Interaction analyses were used to test hypotheses. Results: Maternal parenting stress interacted with maternal involuntary disengagement stress responses in relation to maternal hazardous alcohol use, such that at average and high levels of disengagement stress responses, parenting stress was associated with hazardous alcohol use. These results were robust to covariates (i.e., family income, maternal anxiety symptoms, maternal depressive symptoms, general levels of maternal stress, maternal cigarette use). Maternal disengagement coping strategies were not related to maternal hazardous alcohol use. Conclusion: Results suggest that parenting stress and involuntary disengagement stress responses may be associated with hazardous alcohol use among mothers of adolescents.

Children born to women in opioid maintenance treatment: A longitudinal study of child behavioral problems and parenting stress

In the wake of the "opioid epidemic", there is considerable concern regarding potential harmful long-term effects of prenatal opioid exposure. Opioid misuse and addiction confer increased exposure to lifestyle stressors and health burdens. Accordingly, it is challenging to disentangle effects of prenatal opioid exposure per se from factors related to maternal stress. In this study, we followed 36 women enrolled in comprehensive opioid maintenance treatment (OMT) program and their children alongside 36 age-matched mother-child dyads from a community sample (COMP) from pregnancy until child-age 8 years. Across five sessions, we used a battery of well-established questionnaires to investigate trajectories of parenting stress and mental health symptoms as well as child behavior problems. The 8-year retention was relatively high (OMT: 72%, COMP: 67%), and the OMT sample remarkably stable and well-functioning, with minimal concomitant illicit drug use. Mixed effects regressions showed significantly different trajectories of child behavior problems (F = 3.8, p = 0.024) and parenting stress (F = 3.1, p = 0.016) in the two groups. Differences in experienced stress were largely explained by more distress specifically related to the parenting role in the OMT group (F = 9.7, p = 0.003). The OMT sample also reported higher psychological distress (F = 15.6, p < 0.001) than the comparison group, but notably few participants presented with problems that warranted clinical intervention. The results underscore the benefits of tailored follow-up of children prenatally exposed to opioids and their families beyond infancy and toddlerhood. Long-term direct effects of prenatal opioid exposure on behavior problems are likely modest, given an otherwise stable caregiving environment conducive to healthy development.

"Ask Parents What They Want to Do" - Mothers Seeking Help with Parenting and Their Perspectives on Barriers and Potential Enablers for Help with Smoking Cessation: A Qualitative Study

PURPOSE

To describe parents' perceptions of opportunities and barriers to smoking cessation in early parenting and the support needed to achieve this.

DESIGN AND METHODS

A qualitative approach, using semi-structured interviews with mothers, and inductive thematic analysis.

RESULTS

Barriers to cessation intervention included readiness to quit, lack of knowledge, and the shame and stigma of seeking help. Mothers' perceived opportunities for support from early parenting services included approaches to effecting change, leveraging opportunities to explore smoking cessation, and tailoring interventions to family strengths, with a focus on promoting attachment.

CONCLUSIONS

Mothers may be struggling with parenting, but are also open to opportunities to explore smoking behaviours and intervention. Nurses and other health care professionals working in this setting may be well situated to support parents with their decisions to consider smoking cessation and avoid smoking relapse.

PRACTICE IMPLICATIONS

The findings can assist nurses and other early parenting service clinicians to consider their approach to parents who continue to smoke or are at risk of smoking relapse.

The Value of Mechanistic Experiments to Target the Shared Neural Circuitry of Parenting and Addiction: The Potential for Video Feedback Interventions

Certain neural processes that underlie addiction are also central to parenting, notably stress and reward. Parenting interventions that incorporate the unique context of caregivers with addiction have demonstrated some success: However, real-world implementation of evidence-based interventions can be difficult with this population. Video feedback interventions are an especially promising approach to reach parents who experience barriers to participation, particularly caregivers with addiction. A translational neuroscientific approach to elucidating the mechanisms of change in these interventions will aid the delivery and success of this method and advance theory surrounding parenting in the context of addiction. Along these lines, we provide an example of one video feedback intervention, Filming Interactions to Nurture Development, that will serve as such a mechanistic experiment.

“A Window of Opportunity”: Parenting and Addiction in the Context of Pregnancy

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.

Mediation pathways for reduced substance use among parents in South Africa: a randomized controlled trial

BACKGROUND

Substance use is a major public health concern worldwide. Alcohol and drug use have increased during recent decades in many low- and middle-income countries, with South Africa, where this study was conducted, having among the highest rates in the world. Despite existing evidence on the effectiveness of family-based interventions in reducing substance use among parents and caregivers in low- and middle-income countries, little is known about the mechanism of change that contributes to the reduction. This study investigated mediators of change in a parenting programme (Parenting for Lifelong Health [PLH]) on reducing substance use among parents and caregivers of adolescents through three potential mediators: parental depression, parenting stress and family poverty.

METHODS

The current study used a pragmatic cluster randomized controlled trial design. The total sample comprised 552 parent and caregiver of adolescents M = 49.37(SD = 14.69) who were recruited from 40 communities in South Africa's Eastern Cape. Participants completed a structured confidential self-report questionnaire at baseline and a follow-up test 5 to 9 months after the intervention. Structural equation modeling was conducted to investigate direct and indirect effects.

RESULTS

Analyses indicated that the effect of the PLH intervention on reducing parental substance use was mediated in one indirect pathway: improvement in parental mental health (reduction in parental depression levels). No mediation pathways from the PLH intervention on parental substance use could be associated with parenting stress or family poverty.

CONCLUSIONS

The findings of the study suggest that intervention approaches targeting mental health among parents and caregivers have promise for reducing parental substance use. These findings emphasize the need to create supportive environments and systems for parents who suffer from emotional strain and mental health problems, particularly within families experiencing adversity.

TRIAL REGISTRATION

Pan-African Clinical Trials Registry PACTR201507001119966. Registered on 27 April 2015. The trial can be found by searching for the key word 'Sinovuyo' on the Pan-African Clinical Trials Registry website or via the following link: http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?_nfpb=true&_windowLabel=BasicSearchUpdateController_1&BasicSearchUpdateController_1_actionOverride=%2Fpageflows%2Ftrial%2FbasicSearchUpdate%2FviewTrail&BasicSearchUpdateController_1id=1119.

Mothering from the Inside Out: Addressing the Intersection of Addiction, Adversity, and Attachment with Evidence-Based Parenting Intervention

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.

Dynamics of Parental Opioid Use and Children's Health and Well-Being: An Integrative Systems Mapping Approach

The seemingly intractable opioid epidemic compels researchers, the media, and families to better understand the causes and effects of this complex and evolving public health crisis. The effects of this crisis on people using opioids, maternal prenatal opioid exposure, and neonatal abstinence syndrome are well-documented, but less is known about the impact of caregivers' opioid use on children's health and well-being. One challenge to understanding the effects of parental opioid use disorder (OUD) on child and adolescent outcomes is the numerous interrelated pathways in which a child's health and well-being can be impacted. To better understand these dynamic relationships, we applied a systems mapping approach to visualize complex patterns and interactions between pathways and potential leverage points for interventions. Specifically, we developed a causal loop diagram system map to elucidate the complex and interconnected relationships between parental OUD, social determinants of health at the family and socio-environmental levels, family strengths, social supports, and possible adverse impacts on children's physical and mental health and risks for future substance misuse. The goals of this research are to (1) identify factors and dynamics that contribute to the relationship between parental OUD and children's health and well-being and (2) illustrate how systems mapping as a tool can aid in understanding the complex factors and dynamics of the system(s) that influence the well-being of children and their parents or primary caregivers.

Maternal pre- and postnatal substance use and attachment in young children: A systematic review and meta-analysis

Maternal substance use has often been associated with insecure and disorganized child attachment. We evaluated this association with a meta-analysis of young children and, further, systematically reviewed mediating and moderating factors between maternal substance use and child attachment. We performed a systematic database search of quantitative English language studies on child attachment that included substance-using mothers and their children below 6 years of age. Eleven studies (N = 1,841) met the inclusion criteria and were included in the meta-analysis of attachment security and seven (N = 1,589) studies were included in the meta-analysis of attachment disorganization. We found that maternal substance use was negatively associated with secure attachment in children, but the effect size was small (r = -.10). The association with disorganized attachment was not significant (r = .15). Related to moderating and mediating factors (k = 6), we found evidence on the role of teratogenic and sociological factors on child attachment. Most importantly, the impact of cumulative risks was vital. However, literature was scarce, and studies varied in risk of bias, leaving many unanswered questions on other potential factors underlying the development of attachment in these high-risk children. We discuss the results considering clinical implications and future directions.

Parenting Stress and its Associated Components Prior to an Autism Spectrum Disorder (ASD) Diagnostic Evaluation

Parents of children with autism spectrum disorder (ASD) show increased levels of parenting stress, but only one study has examined this association before a diagnostic evaluation. We conducted a cross-sectional study of parenting stress in 317 low SES parents with children at-risk for ASD before a diagnostic evaluation. Multiple regression modeling evaluated the associations between parenting stress and parent and child factors. Parenting stress was negatively associated with social support and positively associated with active avoidance coping and parental worry. However, parenting stress was not associated with the child's ASD symptom severity or adaptive functioning, except for self-direction. Findings suggest parenting stress among parents of children at risk of ASD should be assessed prior to diagnosis.

How stress can influence brain adaptations to motherhood

Research shows that a woman's brain and body undergo drastic changes to support her transition to parenthood during the perinatal period. The presence of this plasticity suggests that mothers' brains may be changed by their experiences. Exposure to severe stress may disrupt adaptive changes in the maternal brain and further impact the neural circuits of stress regulation and maternal motivation. Emerging literature of human mothers provides evidence that stressful experience, whether from the past or present environment, is associated with altered responses to infant cues in brain circuits that support maternal motivation, emotion regulation, and empathy. Interventions that reduce stress levels in mothers may reverse the negative impact of stress exposure on the maternal brain. Finally, outstanding questions regarding the timing, chronicity, types, and severity of stress exposure, as well as study design to identify the causal impact of stress, and the role of race/ethnicity are discussed.

Neurobiology of peripartum mental illness

At least one in seven pregnant or recently postpartum women will experience a mental illness such as an anxiety disorder, depressive disorder, or substance use disorder. These mental illnesses have detrimental effects on the health of the mother, child, and family, but little is known about the hypothalamic and other neural correlates of maternal mental health concerns. The transition to parenthood alone is a time of remarkable neural plasticity, so it is perhaps not surprising that current research is showing that maternal mental illness has unique neural profiles. Furthermore, the neural systems affected by peripartum mental illness overlap and interact with the systems involved in maternal caregiving behaviors, and mother-infant interactions are, therefore, highly susceptible to disruption. This review discusses what we know about the unique neural changes occurring during peripartum mental illness and the role of the hypothalamus in these illnesses. With an improved understanding of the neural correlates of maternal mental health and disease, we will be better equipped to predict risk, develop effective treatments, and ultimately prevent suffering for millions of parents during this critical time in life.

Maternal alcohol dependence and harsh caregiving across parenting contexts: The moderating role of child negative emotionality

Parental alcohol dependence is a significant risk factor for harsh caregiving behaviors; however, it is unknown whether and how harsh caregiving changes over time and across parenting contexts for alcohol-dependent mothers. Furthermore, to our knowledge, no studies have examined whether and how distinct dimensions of child characteristics, such as negative emotionality modulate harsh caregiving among alcohol-dependent mothers. Guided by parenting process models, the present study examined how two distinct domains of children's negative emotionality-fear and frustration-moderate the association between maternal alcohol dependence and maternal harshness across discipline and free-play contexts. A high-risk sample of 201 mothers and their two-year-old children were studied over a one-year period. Results from latent difference score analyses indicated that harsh parenting among alcohol-dependent mothers increased over time in the more stressful discipline context, but not in the parent-child play context. This effect was maintained even after controlling for other parenting risk factors, including other forms of maternal psychopathology. Furthermore, this increase in harsh parenting was specific to alcohol-dependent mothers whose children were displaying high levels of anger and frustration. Findings provide support for specificity in conceptualizations of child negative emotionality and parenting contexts as potential determinants of maladaptive caregiving among alcohol-dependent mothers.

Alcohol Use Trajectories Before and After Pregnancy Among Adolescent and Young Adult Mothers

BACKGROUND

Moderate to heavy alcohol use during pregnancy (≥3 drinks/occasion) is linked to a range of adverse offspring outcomes. Prior studies suggest that adolescent and young adult mothers may be particularly vulnerable to these risky drinking behaviors during and after pregnancy. This study used latent class growth analysis (LCGA) to examine changes in risky drinking from prepregnancy to postpregnancy and identified prepregnancy predictors representing cognitive and social factors to inform prevention.

METHODS

Participants included 432 adolescent and young adult mothers (aged 13 to 24; 78% Black) assessed annually since childhood in the Pittsburgh Girls Study. Participants prospectively reported frequency of risky drinking (≥3 drinks/occasion) in the year of pregnancy and 2 years before and after pregnancy, as well as social-cognitive risk factors for drinking (alcohol expectancies, drinking motives, caregiver, and peer alcohol use).

RESULTS

Approximately 11% of young mothers in this community-based sample engaged in risky drinking at least once a month during the year of pregnancy, with greater frequency observed for young adult (vs. adolescent) mothers. LCGA revealed 4 risky drinking trajectories across the perinatal period, including 3 relatively stable trajectories (low, moderate, and high frequency) and 1 distinct trajectory ("postpartum initiators") characterized by increased risky drinking post-childbirth. Peer alcohol use during and after pregnancy distinguished higher risk from lower risk trajectories, controlling for age, race, and age of drinking onset. Exposure to caregiver alcohol use and prepregnancy coping motives for drinking also elevated risk, but only for mothers who became pregnant in early adulthood (vs. adolescence).

CONCLUSIONS

Adolescent and young adult mothers show heterogeneous risky drinking trajectories from prepregnancy to postpregnancy. Pregnant women in the transitional age of early adulthood who report exposure to caregiver alcohol use, more friends who drink, and coping motives for drinking may have elevated risk for moderate-heavy drinking during the perinatal period and may benefit from targeted intervention.

Infralimbic Cortex Biases Preference Decision Making for Offspring over Competing Cocaine-Associated Stimuli in New Mother Rats

In the context of drug abuse, converging evidence suggests that cocaine use in new mothers is significantly reduced by the competing motivation related to child rearing. Given the demonstrated importance of the medial prefrontal cortex (mPFC) in decision-making processes, we investigated the contribution of distinct regions of the mPFC [anterior cingulate (Cg1), prelimbic (PrL), infralimbic (IL)] to decision making in new mother rats performing a concurrent pup/cocaine choice conditioned place preference (CPP) task. When given a choice, inactivation of IL cortex significantly biased decision making of mother rats toward cocaine-associated cues, highly contrasting the distribution of preferences by control groups. In contrast, inactivation of PrL cortex had the opposite effect, significantly increasing offspring bias in the decision making, such that none of the mothers chose the cocaine-associated alternative. Cg1 inactivation was without effect. Functional inactivation of these same mPFC subregions had no effect in a non-conflict CPP task in which context-induced cocaine or pup seeking were examined separately. Notably, inactivation of the IL cortex also interfered with maternal behavior. Taken together, we have identified a specific role of the IL cortex in the prioritization of offspring over drug competing alternatives, thus promoting resistance to drug use in new mothers.

A New Parental Mentalization Focused Ultrasound Intervention for Substance Using Pregnant Women. Effect on Self-reported Prenatal Mental Health, Attachment and Mentalization in a Randomized and Controlled Trial

The effect of a novel mentalization-based parenting intervention was explored on prenatal self-reported mentalization (P-PRFQ), attachment (MFAS), depression (EPDS) and anxiety (STAI) among women with substance use problems. The participants were 90 pregnant women referred to obstetric outpatient care due to recent or current substance use and randomized into intervention (n = 46) and control (n = 44) groups. The intervention group received three interactive 4D ultrasound sessions and a week-by-week pregnancy diary. The control condition was constituted of treatment-as-usual in obstetric care. Unfortunately, the efficacy of the intervention on maternal prenatal mental health, attachment, and parental mentalization was not substantiated. The negative results may be related to the small sample size, the patient-reported outcomes, or insufficient efficacy within this high-risk group. In the context of high psychosocial risks and follow-up by Child Welfare Services, the patient-reported outcomes may have underestimated prenatal adversity. The role of the research context, methodology, and possible sources of bias in the outcome assessment are discussed.

The trial registration number in the ClinicalTrials.gov: NCT03413631

Pathways Relating the Neurobiology of Attachment to Drug Addiction

Substance use disorders constitute a significant public health problem in North America and worldwide. Specifically, substance addictions in women during pregnancy or in the postpartum period have adverse effects not only on the mother, but also on mother-infant attachment and the child's subsequent development. Additionally, there is growing evidence suggesting that parental addiction may be transmitted intergenerationally, where the child of parents with addiction problems is more likely to experience addiction as an adult. The current review takes a developmental perspective and draws from animal and human studies to examine how compromised early experience, including insecure attachment, early abuse/neglect, and unresolved trauma, may influence the development of neurobiological pathways associated with addictions, ultimately increasing one's susceptibility to addictions later in life. We approach this from three different levels: molecular, neuroendocrine and behavioral; and examine the oxytocin affiliation system, dopamine reward system, and glucocorticoid stress response system in this regard. Increased understanding of these underlying mechanisms may help identify key targets for early prevention efforts and inform needed intervention strategies related to both insecure attachment and addiction.