Parenting training for women in residential substance abuse treatment. Results of a demonstration project

Parenting outcomes of parenting interventions in integrated substance-use treatment programs: A systematic review

The high prevalence of women in substance use treatment programs with children, and the co-occurring negative physical and mental health outcomes associated with substance use, led to the development of integrated substance use treatment programs that target a range of women-specific issues. Integrated programs typically offer some type of parenting component, although the level of parenting services varies widely. Existing reviews have found positive child and parent outcomes following integrated treatment programs in general, although studies were not selected on the basis of whether they included parenting interventions. Due to the large percentage of substance using parents and research that parenting interventions contribute to decreased maternal substance use, this critical review examines parental outcomes of published studies on integrated programs that specifically include a parenting intervention component, as well as moderators of parenting and parental substance use/relapse. Across the 15 studies identified, this systematic review primarily focused on 8 parenting outcomes, including program retention, substance use, parenting stress, psychosocial adjustment, depression, child abuse potential, parenting behaviors, and parent-child interaction; as well as 5 additional secondary outcomes. The review discusses results on each of these outcomes, as well as retention rates across the parenting interventions.

Attachment Theory and Maternal Drug Addiction: The Contribution to Parenting Interventions

Children's emotional and relational development can be negatively influenced by maternal substance abuse, particularly through a dysfunctional caregiving environment. Attachment Theory offers a privileged framework to analyze how drug addiction can affect the quality of adult attachment style, parenting attitudes and behaviors toward the child, and how it can have a detrimental effect on the co-construction of the attachment bond by the mother and the infant. Several studies, as a matter of fact, have identified a prevalence of insecure patterns among drug-abusing mothers and their children. Many interventions for mothers with Substance Use Disorders have focused on enhancing parental skills, but they have often overlooked the emotional and relational features of the mother-infant bond. Instead, in recent years, a number of protocols have been developed in order to strengthen the relationship between drug-abusing mothers and their children, drawing lessons from Attachment Theory. The present study reviews the literature on the adult and infant attachment style in the context of drug addiction, describing currently available treatment programs that address parenting and specifically focus on the mother-infant bond, relying on Attachment Theory.

Utilization of Substance Abuse Treatment: Gender Differences among Participants in an Aftercare Program

This study examined gender differences in the utilization of substance abuse treatment including inpatient, outpatient, and self-help services, using existing data sets from a National Institute on Drug Abuse study that enrolled 78 females and 141 males in a mixed-gender aftercare program in Massachusetts for a 2-year follow-up period. This study found that women came to the study in greater need of treatment than men. Women utilized significantly more outpatient treatment services than men. The characteristic of female per se led to more utilization of outpatient services, whereas the baseline characteristics of employed status and alcohol use led to less utilization of outpatient services.

Interventions to address parenting and parental substance abuse: conceptual and methodological considerations

Parental substance abuse is a serious problem affecting the well-being of children and families. The co-occurrence of parental substance abuse and problematic parenting is recognized as a major public health concern. This review focuses on 21 outcome studies that tested dual treatment of substance abuse and parenting. A summary of theoretical conceptualizations of the connections between substance abuse and parenting provides a backdrop for the review. Outcomes of the dual treatment studies were generally positive with respect to reduction of parental substance use and improvement of parenting. Research in this area varied in methodological rigor and needs to overcome challenges regarding design issues, sampling frame, and complexities inherent in such a high-risk population. This area of work can be strengthened by randomized controlled trials, use of mixed-methods outcome measures, consideration of parent involvement with child protective services, involvement of significant others in treatment, provision of concrete supports for treatment attendance and facilitative public policies.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2011: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Integration of parenting skills education and interventions in addiction treatment

OBJECTIVES

Children of parents with substance use disorders are at risk for various adverse outcomes, and maladaptive parenting behaviors seem to be an important mediator of this risk. Although numerous research studies have highlighted the promise of parenting interventions in modifying parenting behavior, very little is known about the integration of parenting skills education and interventions into addiction treatment programs.

METHODS

In this study, a convenience sample of 125 addiction treatment programs in the United States was drawn. A key staff member was interviewed to gather basic information about the extent and nature of parenting skills education and interventions offered at their program. In addition, respondents were asked to rate the importance of parenting skills relative to other addiction treatment priorities.

RESULTS

Descriptive analyses revealed that 43% reported some form of parenting classes, but few used a structured curriculum.

CONCLUSIONS

Given the known beneficial influence of effective parenting practices on reducing adverse childhood outcomes, it is surprising that relatively few substance abuse treatment programs have adopted structured parenting skills interventions as part of their standard service offerings. More research is warranted on the extent to which parenting skills interventions are integrated into the continuum of services available to parents with a substance use disorder.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2012: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Parental substance use impairment, parenting and substance use disorder risk

Using data from a nationally representative sample, this study investigated substance use disorder (SUD) among respondents with ages 15-54 years as a function of their parents' substance-related impairment and parents' treatment history. In addition, associations among maternal and paternal substance-related impairment, specific parenting behaviors, and risk for SUD in the proband were examined. As expected, parental substance-related impairment was associated with SUD. Paternal treatment history was associated with a decreased risk for SUD in the proband but did not appear to be associated with positive parenting practices. Results of post hoc analyses suggested that parenting behaviors might operate differently to influence SUD risk in children where parents are affected by substance use problems compared with nonaffected families. Future research is warranted to better understand the complex relationships among parental substance use, treatment, parenting behaviors, and SUD risk in offspring. Opportunities might exist within treatment settings to improve parenting skills.

Gender differences in treatment outcomes among participants in a mixed-gender substance abuse aftercare program

This study examined gender and gender-related predictors in multiple outcomes of substance abuse aftercare treatment among 78 females and 141 males enrolled in a mixed-gender aftercare program in Massachusetts from 1994 to 1996. Female participants entered the program with higher needs than their male counterparts, showing a worse condition in almost all baseline characteristics, of which many are statistically significant. The generalized estimating equations (GEE) model revealed significant gender differences in the two treatment outcomes of employment income and illegal activity days. Also, many significant gender-related predictors and interaction variables were found.

The Haven Mother's House Modified Therapeutic Community: Meeting the gap in infant mental health services for pregnant and parenting mothers with drug addiction

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.

Long-term effects of the Focus on Families project on substance use disorders among children of parents in methadone treatment

AIMS

This study examines the efficacy of the Focus on Families project (currently called Families Facing the Future), a preventive intervention to reduce substance use disorders among children in families with a parent in methadone treatment.

DESIGN

One hundred and thirty families were assigned randomly to a methadone clinic treatment-as-usual control condition or treatment-as-usual plus the Focus on Families intervention between 1991 and 1993. Setting Participants were recruited from two methadone clinics in the Pacific Northwest.

PARTICIPANTS

This study examines the development of substance use disorders among the 177 children (56.84% male) involved in the program using data from a long-term follow-up in 2005, when these participants ranged in age from 15 to 29 years.

INTERVENTION

The intervention was delivered through group parent-training workshops at the methadone clinics and through individualized home-based services. The intervention taught parenting skills and skills for avoiding relapse to drug abuse.

MEASUREMENTS

At long-term follow-up, substance use disorders were measured by the Composite International Diagnostic Interview (CIDI). Survival analyses were used to assess intervention versus control differences in the hazard of developing substance use disorders.

FINDINGS

Overall, intervention and control participants did not differ significantly in risk of developing substance use disorders. However, there was evidence of a significant difference in intervention effect by gender. There was a significant reduction in the risk of developing a substance use disorder for intervention group males compared to control group males (hazard ratio = 0.53, P = 0.03), while intervention versus control differences among females were non-significant and favored the control condition.

CONCLUSIONS

Results from this study suggest that helping parents in recovery focus on both reducing their drug use and improving their parenting skills may have long-term effects on reducing substance use disorders among their male children. However, the overall long-term benefits of this program are not supported by the results for female children.

Relational Psychotherapy Mothers' Group: a randomized clinical trial for substance abusing mothers

The purpose of this study was to ascertain the effectiveness of the Relational Psychotherapy Mothers' Group (RPMG), a supportive parenting group intervention for substance abusing women. Sixty mothers receiving RPMG were compared to 67 women receiving recovery training (RT); both treatments supplemented treatment in the methadone clinics. At the end of the 6-month treatment period, RPMG mothers showed marginally significant improvement on child maltreatment (self-reported) and cocaine abuse based on urinalyses when compared with RT mothers; notably, children of RPMG mothers reported significantly greater improvement in emotional adjustment and depression than children of RT mothers. At 6 months follow-up, however, treatment gains were no longer apparent. Overall, the findings suggest that whereas supportive parenting interventions for substance abusing women do have some preventive potential, abrupt cessation of the therapeutic program could have deleterious consequences.

Parental control, parental warmth, and psychosocial adjustment in a sample of substance-abusing mothers and their school-aged and adolescent children

Parenting interventions for substance-abusing adults have been broadly based on two approaches, one emphasizing parental control as a means to managing children's behavior and the second emphasizing parental warmth and sensitivity as means to fostering children's psychological development. In this investigation, we examined associations of parental control and parental warmth, respectively, with children's behavioral and psychological adjustment in a sample of 98 women enrolled in methadone maintenance and their school-aged and adolescent children. Using collateral data collected during the baseline phase of a randomized clinical trial (Luthar, S. S., Suchman, N. E., & Altomare, M. [in press]. Relational Psychotherapy Mothers Group: A randomized clinical trial for substance abusing mothers [in preparation]), we tested predictions that (a) parental control would be more strongly associated with children's behavioral adjustment and (b) parental warmth would be more strongly associated with children's psychological adjustment. Both predictions were generally confirmed, although some crossover among parenting and child dimensions was also evident. Results support the theoretical stance that parental limit setting and autonomy support, as well as nurturance and involvement, are important factors, respectively, in children's behavioral and psychological adjustment.

Substance abuse treatment for mothers: treatment outcomes and the impact of length of stay

This article examines the treatment outcomes of 305 women enrolled in a comprehensive, residential substance abuse treatment program for pregnant and parenting women and their children. The women were assessed at intake and three times in the year after discharge. Analyses focused on change in client functioning over time, and investigating the impact of length of stay in treatment on client outcomes. Comparisons of clients' functioning before and after treatment suggest significant improvements in a number of domains, including substance use, employment, legal involvement, mental health, parenting attitudes, and risky behaviors. For most outcome domains, results suggest that longer treatment stays are associated with more positive outcomes.

ENHANCING THE EFFECTIVENESS OF RESIDENTIAL TREATMENT FOR SUBSTANCE ABUSING PREGNANT AND PARENTING WOMEN: FOCUS ON MATERNAL REFLECTIVE FUNCTIONING AND MOTHER-CHILD RELATIONSHIP

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.

Development and initial demonstration of a community-based intervention for homeless, cocaine-using, African-American Women

Drug abstinence is difficult to achieve and maintain, especially when clients return to their pretreatment environment. Forging ties with the natural helping networks in the community, such as religious organizations, may reinforce abstinent behaviors established during treatment. This study evaluated Bridges to the Community, a supplemental component to an intensive residential treatment program. Bridges uses members of African-American churches as mentors for recovering women. This demonstration project included 118 female participants with primary cocaine dependence who received either standard treatment or Bridges plus standard treatment. Participants in both groups reduced substance use, risk-taking behaviors, depression, and increased self-esteem. Participants who received Bridges had greater treatment retention, reported 100% cocaine abstinence at follow-up, and were more satisfied with their treatment.

Parenting knowledge among substance abusing women in treatment

The purpose of this study was to assess parenting knowledge and beliefs among drug abusing pregnant and recently postpartum women engaged in a comprehensive substance abuse treatment program. The effects of a parenting skills training program for this population were evaluated. A Parenting Skills Questionnaire was developed and administered to a sample of 73 pregnant and drug-dependent women during their first week of substance abuse treatment and again approximately 7 weeks later, following parenting skills training. The questionnaire was designed to assess whether group and individual parenting sessions changed the subjects' knowledge and beliefs in four parenting domains: newborn care, feeding practices, child development and drug abuse during pregnancy. Pre-intervention scores for all parenting domains were low. Post- vs. pre-intervention comparisons showed significant increases in all domain scores after individual and group parenting skills training. Preliminary results obtained from this clinic-based sample suggest that these substance abusing mothers lacked important parenting knowledge and that this knowledge improved after comprehensive substance abuse treatment that included parenting training.

Collaboration between child welfare and substance-abuse fields: combined treatment programs for mothers

OBJECTIVE

To review collaboration between child welfare and drug-abuse fields in providing treatment to mothers who abuse drugs and maltreat their children.

METHODS

Literature review of studies examining effects of maternal drug abuse on parenting skills and outcomes of interventions for both maternal drug abuse and parenting skills.

RESULTS

Parenting skills differ between mothers who do and do not abuse drugs, but these studies are primarily limited to mothers of infants and preschoolers. The evidence base for interventions to address both substance use and parenting in these mothers is growing, but more well-controlled studies are needed. Opportunities for improved collaboration between fields are presented.

CONCLUSION

Progress has been made toward collaboration to address drug abuse and parenting skills of mothers who abuse drugs, but more integrated strategies are needed, especially for mothers who use drugs and maltreat their children.

Changes in quality of life for pregnant women in substance user treatment: developing a quality of life index for the addictions

Using preference weights from a community sample, items from the Addiction Severity Index (ASI) were converted into a quality of life index (QOLI) and used to compare the cost-effectiveness of five addiction treatment modalities for pregnant women.

METHODS

Interviews using the time trade-off methodology were conducted with 143 members of Massachusetts local health planning boards to determine preference weights for different health states resulting from active addiction. A multi-attribute utility formula was used to convert these seven preference weighted scores into a single QOLI. To apply the QOLI, these preference weights were combined with the number of problem days reported in each ASI domain by a sample of 439 pregnant women in MA in five treatment modalities, 1992-1996.

RESULTS

Starting at 10 years with an addiction problem, board members indicated that they would give up between 0.83 and 3.96 years to avoid the problems in one domain caused by addiction. The average QOLI was 0.68 at intake but increased by 0.19 points by 6-month follow-up to 0.87. All five treatment groups showed notable improvement in their quality of life. Mean improvements ranged from a high of 0.23 QOLIs for clients who received both residential and outpatient treatment to a low of 0.16 for clients who received only detoxification. Treatment costs ranged from 10,187 dollars for residential and outpatient combined to 2535 dollars for detoxification only, with costs per QOLI ranging from 14,912 dollars to 44,291 dollars.

CONCLUSIONS

Although this QOLI could benefit from further refinement and development, it showed promise as a single outcome measure for CEAs in the chemical dependency field. This QOLI was sensitive enough to distinguish between the treatment groups, it correlated well with other outcome measures and can be easily converted from the ASI using spreadsheet software and a simple formula.

Substance abuse treatment for women: Changes in the settings where women received treatment and types of services provided, 1987–1998

Changes in social policies during the last 2 decades have had major implications for the provision of substance abuse treatment services to women. The goal of this analysis was to examine (a) changes in the proportion of women clients served within different types of treatment facilities and (b) the services provided in these facilities. Data were analyzed from national surveys of treatment providers for the period of 1987 to 1998. Overall, there were gradual increases in the proportion of women clients across treatment facilities and greater concentrations of women in more intensive treatment modalities. The provision of childcare increased over time, particularly in programs with only women clients. Treatment facilities in which there were higher proportions of women generally had higher rates of providing services related to pregnancy, parenting, and domestic violence. These findings can be used to assess the adequacy of service delivery to women in substance abuse treatment.

The impact of parental problem drug use on children: what is the problem and what can be done to help?

AIM

To review the literature on the impact of parental problem drug use on children, and indicate the efficacy of key evaluated interventions to reduce the impact of parental drug use on children.

METHODS

Comprehensive narrative review of English language published research and intervention spanning the last three decades identified through searching library databases and citation.

FINDINGS

Problem drug use can impede parenting and the provision of a nurturing environment. Although small-scale, localized and resource-intensive these key evaluated interventions show cautious optimism that problem drug-using parents can reduce drug use and achieve better family management. Children have rarely been directly the focus of intervention.

CONCLUSIONS

Wider application and more rigorous evaluation of interventions in this area are needed. Given the scale of the problem it is important to establish how statutory services can apply the lessons of these more localized interventions.

"New Choices" for women with addictions: perceptions of program participants

Background

Substance use in pregnancy is a major public health problem. It can have profound effects on pregnancy outcomes, and childhood health and development. Additionally, women who use substances have their own health-related issues. Although intervention is important, these women often have difficulty using traditional systems of care. The New Choices program is a centralized, multi-sector approach to service delivery that has attempted to overcome barriers to care by offering one-stop shopping in a supportive environment. As part of an evaluation of this program designed for women who are pregnant and/or parenting young children, interviews were conducted with participants to gain insight into their experiences in New Choices and perceptions of any changes attributed to program involvement.

Methods

A qualitative, exploratory design was used to guide data collection and analysis. Four women participated in a focus group interview and seven women agreed to individual interviews over the course of the program evaluation (N = 11). A semi-structured interview guide was used to explore women's experiences in New Choices and their perceptions of the program and its impact. The interview data were analyzed using NVivo software and an inductive approach to data analysis.

Results

The emergent themes captured women's motivations for attending New Choices, benefits of participation, and overall quality of the program. Children were the primary motivating factor for program enrollment. Perceived benefits included decreased substance use, improved maternal health, enhanced opportunity for employment, increased access to other resources, enhanced parenting skills, and improved child behaviour and development. Women highly valued the comprehensive and centralized approach to service delivery that provided a range of informal and formal supports.

Conclusions

Interview findings endorse the appropriateness and potential efficacy of a collaborative, centralized approach to service provision for women with substance use issues. Although the findings provide insight into an alternative model of service delivery for women with addictions, future research is needed to evaluate the effectiveness of the intervention. Research also is needed to determine which program components or constellation of components contribute to desired outcomes, and to learn more about processes that underlie changes in behaviour.

Parent-training programmes for improving maternal psychosocial health

BACKGROUND

Mental health problems are common and there is evidence to suggest that the origins of such problems lie in infancy and childhood. In particular, there is evidence from a range of studies to suggest that maternal psychosocial health can have a significant effect on the mother-infant relationship, and that this in turn can have consequences for both the short and long-term psychological health of the child. The use of parenting programmes is increasing in the UK and elsewhere and evidence of their effectiveness in improving outcomes for children has been provided. Evidence is now required of their effectiveness in improving outcomes for mothers.

OBJECTIVES

The objective of this review is to address whether group-based parenting programmes are effective in improving maternal psychosocial health including anxiety, depression, and self-esteem.

SEARCH STRATEGY

A range of biomedical, social science, educational and general reference electronic databases were searched including MEDLINE, EMBASE CINAHL, PsychLIT, ERIC, ASSIA, Sociofile and the Social Science Citation Index. Other sources of information included the Cochrane Library (SPECTR, CENTRAL), and the National Research Register (NRR).

SELECTION CRITERIA

Only randomised controlled trials were included in which participants had been randomly allocated to an experimental and a control group, the latter being a waiting-list, no-treatment or a placebo control group. Studies had to include at least one group-based parenting programme, and one standardised instrument measuring maternal psychosocial health.

DATA COLLECTION AND ANALYSIS

A systematic critical appraisal of all included studies was undertaken using a modified version of the Journal of the American Medical Association (JAMA) published criteria. The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group, by the pooled standard deviation, to produce an effect size. Where appropriate the results were then combined in a meta-analysis using a fixed-effect model, and 95% confidence intervals were used to assess the significance of the findings.

MAIN RESULTS

A total of 23 studies were included in the original review which was increased to 26 at the first udate (2003). Of these 20 provided sufficient data to calculate effect sizes. The 20 studies provided a total of 64 assessments of outcome on a range of aspects of psychosocial functioning including depression, anxiety, stress, self-esteem, social competence, social support, guilt, mood, automatic thoughts, dyadic adjustment, psychiatric morbidity, irrationality, anger and aggression, mood, attitude, personality, and beliefs. Data sufficient to combine in a meta-analysis existed for only five outcomes (depression; anxiety/stress; self-esteem; social support; and relationship with spouse/marital adjustment). The results of the meta-analyses show statistically significant results favouring the intervention group for depression; anxiety/stress; self-esteem; and relationship with spouse/marital adjustment. The meta-analysis of the social support data showed no evidence of effectiveness. Of the remaining data that it was not possible to combine in a meta-analysis, approximately 22% of the outcomes measured, showed significant differences between the intervention group and the control group. A further 40% showed non-significant differences favouring the intervention group. Approximately one-third of outcomes showed no evidence of effectiveness.A meta-analysis of the follow-up data on three outcomes was also conducted - depression, self-esteem and relationship with spouse/marital adjustment. The results show that there was a continued improvement in self-esteem, depression, and marital adjustment at follow-up, although the latter two findings were not statistically significant. This review has been updated (2003) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting 03) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting assessment and 2 ongoing studies listed for inclusion at a future update of this review. The size of effect for the main outcomes has not been substantially altered by this update. Additional sensitivity analyses to assess the impact of quasi randomised studies on the result have also been added. Where the quasi randomised studies are excluded from the analysis, the result was found to be slightly more conservative.

REVIEWER'S CONCLUSIONS

It is suggested that parenting programmes can make a significant contribution to the short-term psychosocial health of mothers. However, there is currently a paucity of evidence concerning whether these results are maintained over time, and the limited follow-up data which are available show equivocal results. This points to the need for further evidence concerning the long-term effectiveness of parenting programmes on maternal mental health. Whilst the results of this review are positive overall, some studies showed no effect. Further research is needed to assess which factors contribute to successful outcomes in these programmes with particular attention being paid to the quality of delivery.These results suggest that parenting programmes have a potential role to play in the promotion of mental health.

Family-Focused Substance Abuse Treatment: A Program Evaluation

Until recently, few programs were available for children whose mothers are in recovery. A refinement of the gender-specific model of substance abuse treatment, the "family-focused" approach, has placed increased emphasis on the needs of children and other family members. However, because these programs are relatively new, little is known about the effectiveness of this type of treatment for either the mother or her children. This article presents findings from a three-year evaluation of a family-focused residential treatment program for women and their children. Longitudinal assessment of the mothers indicated that their psychosocial status and parenting attitudes improved over time. Additionally, the mothers remained in treatment longer. At intake, as a group, the children who were birth to three years of age did not exhibit developmental delay. However, developmental concerns were identified for some children in the areas of motor and/or language development. The results reported here provide beginning evidence that family-focused treatment improves retention, psychosocial functioning, and parenting attitudes of pregnant and parenting women. It also provides a mechanism for early identification and intervention for children.

Ethical considerations in caring for women with substance use disorders

People living with addiction endure many hardships, and this may be especially true for women who face distinct clinical and significant psychologic and socioeconomic repercussions of addictive disorders and their companion stresses. Clinicians who work with women with addictions are confronted by many challenges, particularly in the care of pregnant and parenting women. The dilemmas faced by patients with addictions and their providers often arise directly from tensions among core ethical principles, from inconsistencies in the way these principles are applied, and from the pervasive effects of stigma. Although difficult issues are to be expected in the arena of substance abuse treatment, consideration of principles of voluntarism, beneficence, respect for persons and justice, confidentiality and truth-telling, and informed consent are invaluable in shaping clinical ethical decision making. Furthermore, proactive steps can be taken to enhance the ethical caliber of care. These steps involve policy-level and systemic actions, such as the development and expansion of programs serving women's unique needs, empiric research into the most effective treatments for women with various disorders, and reexamination of legal and societal stances toward pregnant and parenting women who have addictions. In addition, local and individual steps are needed, including addressing gaps or inherent biases in programs, training counselors and clinicians in effective strategies or counseling styles, and developing awareness of one's own attitudes when dealing with difficult patients and challenging disorders. Such efforts will help ensure that women who have addictions will be cared for in a manner that is respectful, beneficent, compassionate, honest, and just.

Programmes for the children of illicit drug-using parents: issues and dilemmas

Concern about the health and general well-being of children whose parents use illicit drugs has contributed to an increased interest in intervention programmes, but the number of such services is still limited. We review published papers about residential, home-visiting and non-residential programmes and use these and our experience in studying playgroup-based clinics to outline issues and dilemmas they face. These include balancing trust and acceptance with intervention when problems are identified, harmonizing accessibility and flexibility with the provision of child-focused activities and adult education, finding a location that is both suitable and affordable, appropriately supporting staff, collaborating with other services and securing adequate funding, including for ongoing evaluation and monitoring.

Gender differences in detoxification: predictors of completion and re-admission

This study examined the medical records of 2595 consecutive admissions over a 3-year period to an inpatient mixed-gender, hospital-based alcohol and drug detoxification unit. Women reported a significantly different pattern of primary drug use, a younger age, a different pattern of referral sources, and higher rates of parenting status and unemployment. In addition, females were administered prescription medication and medical evaluation tests at a significantly higher rate than males. Multiple regression analyses demonstrated that an opiate as a primary drug of choice was a significant risk factor for dropout. Risk factors for re-admission to inpatient detoxification included: alcohol as a primary drug of choice, residential instability, multiple drug use, single marital status, unemployment, an older age (> 37 years), and treatment dropout at Time 1 in the study. For both the final prediction models, gender was not a significant factor. The treatment implications of these findings are discussed.

The impact of substance abuse treatment modality on birth weight and health care expenditures

During the 1990s, substance abuse treatment programs were developed for pregnant women to help improve infant birth outcomes, reduce maternal drug dependency and promote positive lifestyle changes. This study compared the relative impact of five treatment modalities--residential, outpatient, residential/outpatient, methadone and detoxification-only--on infant birth weight and perinatal health care expenditures for a sample of 445 Medicaid-eligible pregnant women who received treatment in Massachusetts between 1992 and 1997. Costs and outcomes were measured using the Addiction Severity Index and data from birth certificates, substance abuse treatment records and Medicaid claims. Multiple regression was used to control for intake differences between the groups. Results showed a near linear relationship between birth weight and amount of treatment received. Women who received the most treatment (the residential/outpatient group) delivered infants who were 190 grams heavier than those who received the least treatment (the detoxification-only group) for an additional cost of $17,211. Outpatient programs were the most cost-effective option, increasing birth weight by 139 grams over detoxification-only for an investment of only $1,788 in additional health care and treatment costs. A second regression using five intermediate treatment outcomes--prenatal care, weight gain, relapse, tobacco use and infection--suggested that increases in birth weight were due primarily to improved nutrition and reduced drug use, behaviors which are perhaps more easily influenced in residential settings.

Parent-training programmes for improving maternal psychosocial health

BACKGROUND

Mental health problems are common, and there is evidence from a range of studies to suggest that a number of factors relating to maternal psychosocial health can have a significant effect on the mother-infant relationship, and that this can have consequences for both the short and long-term psychological health of the child. The use of parenting programmes is increasing in the UK and evidence of their effectiveness in improving outcomes for mothers is now required.

OBJECTIVES

The objective of this review is to address whether group-based parenting programmes are effective in improving maternal psychosocial health including anxiety, depression, and self-esteem.

SEARCH STRATEGY

A range of biomedical, social science, educational and general reference electronic databases were searched including MEDLINE, EMBASE CINAHL, PsychLIT, ERIC, ASSIA, Sociofile and the Social Science Citation Index. Other sources of information included the Cochrane Library (SPECTR, CENTRAL), and the National Research Register (NRR).

SELECTION CRITERIA

Only randomised controlled trials were included in which participants had been randomly allocated to an experimental and a control group, the latter being either a waiting-list, no-treatment or a placebo control group. Studies had to include at least one group-based parenting programme, and one standardised instrument measuring maternal psychosocial health.

DATA COLLECTION AND ANALYSIS

A systematic critical appraisal of all included studies was undertaken using a modified version of the Journal of the American Medical Association (JAMA) published criteria. The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group, by the pooled standard deviation, to produce an effect size. Where appropriate the results were then combined in a meta-analysis using a fixed-effect model, and 95% confidence intervals were used to assess the significance of the findings.

MAIN RESULTS

A total of 23 studies were included in the review but only 17 provided sufficient data to calculate effect sizes. The 17 studies provided a total of 59 assessments of outcome on a range of aspects of psychosocial functioning including depression, anxiety, stress, self-esteem, social competence, social support, guilt, mood, automatic thoughts, dyadic adjustment, psychiatric morbidity, irrationality, anger and aggression, mood, attitude, personality, and beliefs. There was only sufficient data, however, on five outcomes (depression; anxiety/stress; self-esteem; social support; and relationship with spouse/marital adjustment) to combine the results in a meta-analysis. The meta-analyses show statistically significant results favouring the intervention group as regards depression; anxiety/stress; self-esteem; and relationship with spouse/marital adjustment. The meta-analysis of the social support data, however, showed no evidence of effectiveness. These results suggest that parenting programmes, irrespective of the type (or content) of programme, can be effective in improving important aspects of maternal psycho-social functioning. Of the data summarising the effectiveness of the different types of parenting programmes, which it was not possible to combine in a meta-analysis, approximately 22% of the outcomes measured, showed significant differences between the intervention group and the control group. A further 40% showed medium to large non-significant differences favouring the intervention group. Approximately one-third of outcomes showed small non-significant differences or no evidence of effectiveness. A meta-analysis of the follow-up data on three outcomes was also conducted - depression, self-esteem and relationship with spouse/marital adjustment. The results show that there was a continued improvement in self-esteem, depression and marital adjustment at follow-up, although the latter two findings were not statistically significant.

REVIEWER'S CONCLUSIONS

It is suggested that parenting programmes can make a significant contribution to short-term psychosocial health in mothers, and that the limited follow-up data available suggest that these are maintained over time. However, the overall paucity of long-term follow-up data points to the need for further evidence concerning the long-term effectiveness of parenting programmes on maternal mental health. Furthermore, it is suggested that some caution should be exercised before the results are generalised to parents irrespective of the level of pathology present, and that further research is still required.