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.

Enhancing parental reflective functioning: A special tribute to the life and work of Nancy E. Suchman, PhD

Nancy E. Suchman's contributions to the fields of infant mental health, maternal reflective functioning, and attachment-based intervention will have long-lasting impacts. In particular, through the development and dissemination of her intervention program, Mothering from the Inside Out (MIO), she innovated a way of working with mothers with substance use disorders that represented a paradigm shift within the field of addiction. In this introduction to the special issue, written to honor her life and work, we review Nancy's background and briefly describe her academic accomplishments. The special issue contains nine qualitative and quantitative research reports written by Nancy's colleagues and their collaborators. All nine papers pertain to the theme of understanding, measuring, and promoting parents' capacity for reflective functioning. Four provide findings that advance our understanding of parental reflective functioning. The other five highlight insights from continuing evaluations of MIO, including new adaptations of the model. To introduce the special issue, we provide an overview of the scope of the work done within these projects. Finally, the special issue concludes with two commentaries contributed by Linda Mayes and Arietta Slade, leading scholars within the field who were also Nancy's close colleagues. Both provide insight into Nancy's impact on the field.

Self-report measure of parental reflective functioning: A study of reliability and validity across three samples of varying clinical risk

The Parental Reflective Functioning Questionnaire (PRFQ) provides an efficient way to measure a parent's capacity to recognize their child's mental states and to understand the relationship between underlying mental states and behavior. To date, limited work evaluates its psychometric properties beyond initial validation studies. Here we examined the reliability and validity of the PRFQ in three samples of varying clinical risk (e.g., community sample, previous mental health diagnosis, substance use disorder diagnosis). Across samples, the majority (e.g., 75%-78%) of mothers identified as White; all mothers were from the USA. We compared the PRFQ to task-based measures of mentalization, the Parent Development Interview (PDI), and measures of the parent-child relationship. The PRFQ was a reliable measure across samples, and it was associated in theoretically consistent ways with task-based measures of mentalization. Parental RF across the PDI and PRFQ were not highly correlated in a sample of mothers with substance use disorders. Existing RF measures may be tapping into a different component of the broader construct of parental reflective functioning (PRF). The PRFQ was further validated by demonstrating relationships with parent-report measures of the parent-child relationship. Taken together, these findings provide additional support for the reliability and validity of the PRFQ.

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.

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.

A randomized pilot trial of two parenting interventions for fathers in residential substance use disorder treatment

Residential substance misuse treatment programs for men typically do not integrate treatment for intimate partner violence (IPV) or parenting despite significant overlap between substance misuse, IPV and child maltreatment. A randomized trial compared two fatherhood focused interventions in 6-month residential substance misuse treatment programs. Fathers for Change (F4C) is an integrated intervention targeting IPV and child maltreatment. Dads 'n' Kids (DNK) is a psychoeducational intervention focused on child development and behavioral parenting skills. Sixty-two fathers were randomly assigned to F4C or DNK. They received 12 weeks of individual treatment while in the residential facility and were offered 4 aftercare sessions following discharge. They were assessed prior to treatment, at the time of residential discharge, following completion of the intervention booster sessions, and 3 months following intervention. Overall, both groups showed significant reductions in affect dysregulation, anger, and IPV. F4C fathers showed significantly greater decreases in affect dysregulation problems. There were no significant differences between groups on IPV but men who received F4C may have been less likely to use substances after leaving residential treatment. Integration of fatherhood focused interventions were possible and welcomed by residents at the facilities. F4C showed some benefit over DNK in terms of affect dysregulation symptoms and substance use relapse.

IMPLEMENTATION OF AN EVIDENCED-BASED PARENTING PROGRAM IN A COMMUNITY MENTAL HEALTH SETTING

The process of mental health intervention implementation with vulnerable populations is not well-described in the literature. The authors worked as a community-partnered team to adapt and pilot an empirically supported intervention program for mothers of infants and toddlers in an outpatient mental health clinic that primarily serves a low-income community. We used qualitative ethnographic methods to document the adaption of an evidence-based intervention, Mothering from the Inside Out, and the pilot implementation in a community mental health clinic. Seventeen mothers and their identified 0- to 84-month-old children were enrolled in the study. Key lessons from this implementation include (a) the importance of formative work to build community relationships and effectively adapt the intervention to meet the needs of the therapists and their clients, (b) the importance of designing plans for training and reflective supervision that fit within the flow of the clinic and can tolerate disruptions, and (c) that use of an interdisciplinary approach is feasible with the development of a plan for communication and the support of a trained reflective clinical supervisor. These key lessons advance the scientific knowledge available to healthcare managers and researchers who are looking to adapt mental health clinical interventions previously tested in clinical trials to implementation in community settings.

Does improvement in maternal attachment representations predict greater maternal sensitivity, child attachment security and lower rates of relapse to substance use? A second test of Mothering from the Inside Out treatment mechanisms

In this study, we replicated a rigorous test of the proposed mechanisms of change associated with Mothering from the Inside out (MIO), an evidence-based parenting therapy that aims to enhance maternal reflective functioning and mental representations of caregiving in mothers enrolled in addiction treatment and caring for young children. First, using data from 84 mothers who enrolled in our second randomized controlled trial, we examined whether therapist fidelity to core MIO treatment components predicted improvement in maternal reflective functioning and mental representations of caregiving, even after taking fidelity to non-MIO components into account. Next, we examined whether improvement in directly targeted outcomes (e.g., maternal mentalizing and mental representations of caregiving) led to improvements in the indirectly targeted outcome of maternal caregiving sensitivity, even after controlling for other plausible competing mechanisms (e.g., improvement in maternal psychiatric distress and substance use). Third, we examined whether improvement in targeted parenting outcomes (e.g., maternal mentalizing, mental representations of caregiving and caregiving sensitivity) was associated in improvement in child attachment status, even after controlling for competing mechanisms (e.g., improvement in maternal psychiatric distress and substance use). Finally, we examined whether improvement in maternal mentalizing and caregiving representations was associated with a reduction in relapse to substance use. Support was found for the first three tests of mechanisms but not the fourth. Implications for future research and intervention development are discussed.

Does maternal reflective functioning mediate associations between representations of caregiving with maternal sensitivity in a high-risk sample?

Although it is known that mothers with substance abuse disorders struggle to provide adequate parenting to their children, little is understood about the mechanisms behind this. This cross-sectional study uses an attachment perspective to examine whether reflective functioning mediates the relationship between mental representations of caregiving and maternal sensitivity, in an ethnically diverse sample of 142 substance-abusing mothers (M [SD] = 29.83 [5.79] years of age) and their toddlers (M [SD] = 24.04 [15.15] months of age). Data were baseline measures from two randomized controlled trials. The three variables of primary interest were positively correlated. As expected, there was a significant relationship between mental representations of caregiving and maternal sensitivity that was largely explained by reflective functioning. Confounding and alternate explanations were not supported by a secondary data analyses. The findings underscore the importance of reflective functioning in positive parenting within this high-risk population of mothers, and they provide support for the development of attachment-based interventions.

Mothering from the Inside Out: results of a pilot study testing a mentalization-based therapy for mothers enrolled in mental health services

Mothers who are involved with mental health services (for themselves or their children) rarely receive adequate support for their role as parents. Mental illness in a parent or child often exacerbates the challenges of managing psychological distress that is germane to the parenting roll. Mentalization-based approaches to psychotherapy for parents have the potential to address challenges of emotional regulation in parents by supporting their capacity to recognize and modulate negative affect during stressful parenting situations. In this study, we piloted Mothering from the Inside Out (MIO) with 17 mothers receiving services at a community-based mental health clinic. MIO is a 12-week, mentalization-based parenting intervention that demonstrated efficacy in two previous randomized controlled trials with substance using mothers. In this study, we were interested in determining whether community-based clinicians could deliver MIO with sustained fidelity. We were also interested in examining the preliminary feasibility, acceptability and efficacy of MIO when delivered by clinicians in a community mental health center. Finally, we were interested in replicating prior tests of the proposed treatment mechanisms. Treatment outcomes included maternal reflective functioning, psychiatric and parenting stress, and mother-child interaction quality. Our findings indicated that MIO was feasible and acceptable when delivered in the community-based setting and that all maternal indices improved. However, no improvement in mother-child interaction quality was found, possibly because of insufficient time for these changes to consolidate.

All-data approach to assessing financial capability in people with psychiatric disabilities

The goal of this project was to develop an evidence-based method to assess the ability of disabled persons to manage federal disability payments. This article describes the development of the Financial Incapability Structured Clinical Assessment done Longitudinally (FISCAL) measure of financial capability. The FISCAL was developed by an iterative process of literature review, pilot testing, and expert consultation. Independent assessors used the FISCAL to rate the financial capability of 118 participants (57% female, 58% Caucasian) who received Social Security disability payments, had recently been treated in acute care facilities for psychiatric disorders, and who did not have representative payees or conservators. Altogether, 48% of participants were determined financially incapable by the FISCAL, of whom 60% were incapable because of unmet basic needs, 91% were incapable because of spending that harmed them (e.g., on illicit drugs or alcohol), 56% were incapable because of both unmet needs and harmful spending, and 5% were incapable because of contextual factors. As expected, incapable individuals scored higher on a measure of money mismanagement (p < .001) compared with capable individuals. Interrater reliability for FISCAL capability determinations was very good (κ = .77) and interrater agreement was 89%. In this population, the FISCAL had construct validity; ratings demonstrated good reliability and correlated with a related measure. Potentially, the FISCAL can be used to validate other measures of capability and to help understand how people on limited incomes manage their funds.

Gender moderates the relationship between impulsivity and sexual risk-taking in a cocaine-using psychiatric outpatient population

Adults who abuse substances are at increased risk for contracting sexually transmitted infections, including HIV. Within this population, sexual risk behaviors have been associated with increased impulsivity. Studies in non-clinical populations showing gender-related differences in sexual decision-making and casual sexual partnering suggest impulsivity has a greater influence on men than women, but these differences have not been documented in substance-using patients. In a sample of 89 adults with recent cocaine use and receiving outpatient psychiatric treatment, we tested the hypothesis that gender moderates the effect of impulsivity on sexual risk-taking. Using logistic regression modeling, we tested the main and gender-moderated effects of task-related impulsivity on the probability of having a casual sexual partner and multiple sexual partners. Results confirmed a significant gender-by-impulsivity interaction; men who were more impulsive on a continuous performance task had significantly higher rates of sexual risk-taking than less impulsive men, but women's impulsivity was unrelated to these outcomes. Impulsive men were over three times as likely as less impulsive men to have a recent casual partner. Implications of these results and suggestions for future research are discussed.

Ambiguity in determining financial capability of SSI and SSDI beneficiaries with psychiatric disabilities

OBJECTIVE

The liberty of individuals who receive Social Security disability payments is constrained if they are judged incapable of managing their payments and are assigned a payee or conservator to manage benefit payments on their behalf. Conversely, beneficiaries' well-being may be compromised if they misspend money that they need to survive. Several studies have shown that determinations of financial capability are made inconsistently and that capability guidelines appear to be applied inconsistently. This article describes ambiguities that remained for individuals even after a comprehensive assessment of financial capability was conducted by independent assessors.

METHODS

Trained, experienced assessors rated the financial capability of 118 individuals in intensive outpatient or inpatient psychiatric facilities who received Social Security Disability Insurance or Supplemental Security Income.

RESULTS

Ten individuals' cases were determined to be difficult to judge. Six sources of ambiguity were identified by case review: distinguishing incapability from the challenges of navigating poverty, the amount of nonessential spending that indicates incapability, the amount of spending on harmful things that indicates incapability, how to consider intermittent periods of capability and incapability, the relative weighting of past behavior and future plans to change, and discrepancies between different sources of information.

CONCLUSIONS

The cases raise fundamental questions about how to define and identify financial incapability, but they also illustrate how detailed consideration of beneficiaries' living situations and decision making can inform the difficult dichotomous decision about capability.

Expressive writing as a therapeutic process for drug-dependent women

BACKGROUND

Although women with substance use disorders (SUDs) have high rates of trauma and posttraumatic stress, many addiction programs do not offer trauma-specific treatments. One promising intervention is Pennebaker's expressive writing, which involves daily, 20-minute writing sessions to facilitate disclosure of stressful experiences.

METHODS

Women (N = 149) in residential treatment completed a randomized clinical trial comparing expressive writing with control writing. Repeated-measures analysis of variance was used to document change in psychological and physical distress from baseline to 2-week and 1-month follow-ups. Analyses also examined immediate levels of negative affect following expressive writing.

RESULTS

Expressive writing participants showed greater reductions in posttraumatic symptom severity, depression, and anxiety scores, when compared with control writing participants at the 2-week follow-up. No group differences were found at the 1-month follow-up. Safety data were encouraging: although expressive writing participants showed increased negative affect immediately after each writing session, there were no differences in pre-writing negative affect scores between conditions the following day. By the final writing session, participants were able to write about traumatic/stressful events without having a spike in negative affect.

CONCLUSIONS

Results suggest that expressive writing may be a brief, safe, low-cost, adjunct to SUD treatment that warrants further study as a strategy for addressing posttraumatic distress in substance-abusing women.

An exploratory randomized controlled trial of a novel high-school-based smoking cessation intervention for adolescent smokers using abstinence-contingent incentives and cognitive behavioral therapy

BACKGROUND

There are few effective smoking cessation interventions for adolescent smokers. We developed a novel intervention to motivate tobacco use behavior change by (1) enhancing desire to quit through the use of abstinence-contingent incentives (CM), (2) increasing cessation skills through the use of cognitive behavioral therapy (CBT), and (3) removing cessation barriers through delivery within high schools.

METHODS

An exploratory four-week, randomized controlled trial was conducted in Connecticut high schools to dismantle the independent and combined effects of CM and CBT; smokers received CM alone, CBT alone, or CM+CBT. Participants included 82 adolescent smokers seeking smoking cessation treatment. The primary outcome was seven-day end-of-treatment (EOT) point prevalence (PP) abstinence, determined using self-reports confirmed using urine cotinine levels. Secondary outcomes included one-day EOT PP abstinence and cigarette use during treatment and follow up.

RESULTS

Among participants who initiated treatment (n=72), group differences in seven-day EOT-PP abstinence were observed (χ(2)=10.48, p<0.01) with higher abstinence in the CM+CBT (36.7%) and CM (36.3%) conditions when compared with CBT (0%). One-day EOT-PP abstinence evidenced similar effects (χ(2)=10.39, p<0.01; CM+CBT: 43%, CM: 43%, CBT: 4.3%). Survival analyses indicated differences in time to first cigarette during treatment (χ(2)=8.73, p=0.003; CBT: Day 3, CM: Day 9, CM+CBT: Day 20). At one- and three-month follow ups, while no differences were observed, the CM alone group had the slowest increase in cigarette use.

CONCLUSIONS

High-school, incentive-based smoking cessation interventions produce high rates of short-term abstinence among adolescent smokers; adding cognitive behavioral therapy does not appear to further enhance outcomes.

Parenting of men with co-occurring intimate partner violence and substance abuse

No studies to date have compared parenting behaviors of men with co-occurring intimate partner violence (IPV) and substance abuse (SA) with community controls. This study was designed to document mediators of differences in parenting behavior of fathers and the emotional-behavioral problems of their children for men with co-occurring SA and IPV. The self-reported parenting (negative, positive and coparenting behaviors) and the child emotional-behavioral problems of 43 fathers with children aged 2 to 6 years with a recent history of SA + IPV were compared to a sample of 43 community control fathers with the same socioeconomic and cultural backgrounds. Fathers completed measures on their parenting behavior with a target child, coparenting behavior with the child's mother, emotion regulation, romantic attachment, psychiatric symptoms, and the behavior of the target child. Men with co-occurring SA + IPV had significantly less positive coparenting and more negative parenting behaviors than community control fathers. Negative parenting and coparenting were mediated by the fathers' avoidant attachment problems. SA + IPV fathers also reported more emotional and behavioral problems in their children. These poor child outcome differences between groups were mediated by the negative parenting behaviors of the fathers. These results suggest areas of potential focus in interventions with fathers who have co-occurring SA + IPV issues. Focus on attachment difficulties with his coparent, which may include affect regulation, coping with emotions, and communication skills training related to coparenting, may yield significant changes in parenting behaviors and ultimately child functioning.

ATTACHMENT-BASED INTERVENTION FOR SUBSTANCE-USING MOTHERS: A PRELIMINARY TEST OF THE PROPOSED MECHANISMS OF CHANGE

Although randomized controlled trials examining the efficacy of attachment-based interventions have been increasing in recent years, adequate measurement of treatment integrity, integrity-outcome associations, and mechanisms of change has been rare. The aim of this investigation was to conduct a rigorous test of proposed mechanisms of change in the Mothers and Toddlers Program (MTP) treatment model, a 12-session, attachment-based individual therapy for substance-using mothers of children birth to 3 years of age. The MTP aims to improve maternal reflective functioning (RF) and representation quality (RQ) to bring about second-order change in maternal caregiving behavior. Following guidelines from M.K. Nock (2007), it was hypothesized that (a) therapist adherence to unique MTP treatment components would uniquely predict improvement in RF and RQ and that (b) improvement in RF and RQ would function as unique mechanisms of change (when compared with other potential mechanisms-reduction in depression and increase in abstinence from drug use) in the improvement of caregiving behavior. Findings supported each hypothesis, confirming the proposed mechanisms of the treatment model. However, improvement in maternal depression also uniquely predicted improvement in caregiving behavior. Results underscore the potential value of attachment-based parenting interventions for improving mother-child relations and the importance of providing these interventions in clinic settings where mothers have access to comprehensive care (e.g., psychiatric services).

Sensation seeking, coping with stress, and readiness to engage in therapy: does ego development influence the psychosocial functioning of substance-abusing mothers?

Ego development, the capacity to derive coherent, nuanced meaning from one's life experiences, often has significant impact on psychosocial adjustment during adulthood. Research with nonclinical populations has indicated links between higher ego development and healthy emotional coping and interpersonal relationships. Emerging research with substance-abusing mothers suggests that higher levels of ego development are associated with improved parenting but also with increased rates of psychopathology. Less is known about how ego development is related to other psychosocial factors important for substance-abusing mothers' functioning and capacity to parent, including the proclivity to engage in risky behaviors, adaptive coping behaviors, and readiness to engage in psychotherapy. The present study examines these links. Participants included 182 methadonemaintained women who expressed interest in a randomized clinical trial testing the efficacy of a relational parenting intervention for substance-abusing mothers (Luthar, Suchman, & Altomare, 2007). Data were analyzed using a series of MANCOVAs and ANCOVAs controlling for maternal IQ and depression. Mothers with higher levels of ego development reported more adaptive coping techniques and greater readiness to engage in psychotherapy but also reported a heightened desire for strong sensations. Findings are discussed in light of mothers' psychological processes and parenting capacities. The significance of findings for developing parenting interventions for substance-abusing mothers is also discussed.

Socioeconomic Context and Emotional-Behavioral Achievement Links: Concurrent and Prospective Associations Among Low- and High-Income Youth

Temporal associations in the relationship between emotional-behavioral difficulty and academic achievement were explored in 2 samples followed from 6th through 8th grade. The first sample comprised 280 students entering an economically disadvantaged urban middle school and the second comprised 318 students entering an affluent suburban middle school. Among disadvantaged youth, emotional indices were concurrently associated with poorer achievement while prospective associations between substance use and achievement were evident. For privileged adolescents, only a significant concurrent relationship emerged between social anxiety and achievement, although nonsignificant trends in the data suggest other, albeit weak, associations. The findings are discussed in terms of similarities and differences in these temporal associations across 2 samples representing extremes of the socioeconomic continuum.

Fathers entering substance abuse treatment: An examination of substance abuse, trauma symptoms and parenting behaviors

OBJECTIVE

The relationship between fatherhood and both psychiatric distress and severity of substance abuse (SA) among men entering SA treatment has not been well explored. This study was designed to (a) examine differences in symptoms of men presenting for SA assessment based on fatherhood status and (b) determine how posttraumatic stress disorder (PTSD) symptoms and severity of SA were associated with parenting for men who were fathers.

METHODS

PTSD symptoms, severity of SA, and parenting data reported on structured questionnaires were collected from 126 men presenting for an SA evaluation at a forensic drug diversion clinic.

RESULTS

There were no differences in severity of alcohol or drug use between fathers and nonfathers; however, fathers with more PTSD symptoms reported greater severity of alcohol and drug use. Among the fathers, PTSD symptoms correlated significantly and positively with negative parenting behaviors, whereas SA did not. Fathers with more significant PTSD symptoms were more likely to want help with parenting.

CONCLUSIONS

Further exploration of the impact of trauma-related symptoms on the parenting behaviors of substance-abusing men is warranted.

Commentary: Building a developmental-ecological model of criminal culpability during adolescence

In this issue of The Journal, Dr. Peter Ash offers the American Academy of Psychiatry and the Law some ideas on developmentally informed assessment of criminal culpability during adolescence. After highlighting issues that complicate the definition and assessment of criminal culpability, Ash lists 10 constructs that he believes should be carefully considered by forensic clinicians in developing opinions about legal responsibility for a crime committed by a minor. I applaud Ash for beginning a dialogue on the clinical dimension of this topic, and I appreciate his emphasis on the need for developmentally informed assessment of juvenile defendants. In this commentary, I briefly illustrate how the principles of developmental psychopathology can be used to articulate a developmental-ecological model of criminal culpability for use by forensic clinicians in the assessment of younger defendants, as the courts more broadly accept the concept of mitigation of legal responsibility by reason of developmental immaturity.

College Student Drug Use: Patterns, Concerns, Consequences, and Interest in Intervention

Although previous surveys have indicated high rates of illicit and prescription drug misuse among college students, few have assessed negative consequences, personal concerns, or interest in interventions for drug use. In a survey of 262 college students who self-reported lifetime use of an illicit drug, 69% reported at least one negative consequence over the course of their lifetime and 63% in the past year. Many also reported being moderately concerned (28%) about their drug or medication misuse and moderately interested in some form of intervention (76%). The frequency of marijuana use and medication misuse in the past month was related to increased negative consequences and personal concerns even when controlling for the frequency of past month alcohol use. There were relatively few differences as a function of gender or year in college.

THE MOTHERS AND TODDLERS PROGRAM, AN ATTACHMENT-BASED PARENTING INTERVENTION FOR SUBSTANCE-USING WOMEN: RESULTS AT 6-WEEK FOLLOW-UP IN A RANDOMIZED CLINICAL PILOT

Previously, we reported posttreatment findings from a randomized pilot study testing a new attachment-based parenting intervention for mothers enrolled in substance-use treatment and caring for children ages birth to 3 years (N.E. Suchman, C. DeCoste, N. Castiglioni, T. McMahon, B. Rounsaville, & L. Mayes, 2010). The Mothers and Toddlers Program (MTP) is a 12-session, weekly individual parenting therapy that aims to enhance maternal capacity for reflective functioning and soften harsh and distorted mental representations of parenting. In a randomized pilot study, 47 mothers who were enrolled in outpatient substance-abuse treatment and caring for children between birth and 3 years of age were randomized to the MTP versus the Parent Education Program (PE), a comparison intervention that provided individual case management and developmental guidance. At the end of treatment, mothers in the MTP condition demonstrated better reflective functioning, representation quality, and caregiving behavior than did mothers in the PE condition. In this investigation, we examined whether the benefits of MTP at posttreatment were sustained at the 6-week follow-up. Recently, we also identified two components of parental reflective functioning: (a) a self-focused component representing the parent's capacity to mentalize about strong personal emotions (e.g., anger, guilt, or pain) and their impact on the child and (b) a child-focused component representing the parent's capacity to mentalize about the child's emotions and their impact on the mother (N. Suchman, C. DeCoste, D. Leigh, & J. Borelli, 2010). In this study, we reexamined posttreatment outcomes using these two related, but distinct, constructs.

Drug abuse and intimate partner violence: a comparative study of opioid-dependent fathers

Because very little is known about the coparenting relationships of drug-abusing men, this comparative study was designed to examine the lifetime prevalence and recent frequency of intimate partner violence in the coparenting relationships of 106 fathers enrolled in methadone maintenance treatment. When compared with 118 community controls, the opioid-dependent fathers reported greater prevalence of physical, sexual, and psychological aggression directed at the mother of their youngest biological child over the course of the relationship. They also reported more frequent physical, sexual, and psychological aggression directed at the mother during the previous year. Similarly, the opioid-dependent fathers reported both greater prevalence of physical and sexual aggression directed at them by the mother of their youngest child over the course of the relationship and more frequent sexual aggression directed at them over the previous year. The results highlight the need for clinicians to consider risk for intimate partner violence in coparenting relationships when planning family-oriented intervention designed to meet the needs of fathers, mothers, and children affected by chronic drug abuse.

Maladaptive Coping as a Mediator of Family Stress

Family members of women substance users may be at risk for stress-related problems. Family coping responses may affect outcomes for both families and women in treatment. Eighty-two women in treatment for substance use disorders (56 with comorbid psychiatric conditions) and 82 family members were interviewed. Stressors related to women's disorders were significantly related to increased family member burden. Women's behavioral problems predicted greater family member Worry, Displeasure, and Impact. Extent of women's drug or alcohol use predicted greater family member Stigma and Impact. Family member maladaptive coping partially mediated relationships between family member stressors and family member Displeasure and Impact. Family member maladaptive coping also functioned as a moderator between the stressors and Impact.

The impact of fatherhood on treatment response for men with co-occurring alcohol dependence and intimate partner violence

OBJECTIVE

The role of fathers in the lives of children has gained increasing attention over the last several decades, however, studies that specifically examine the parenting role among men who are alcohol dependent and have co-occurring intimate partner violence (IPV) have been limited. This brief report is intended to highlight the need to develop and focus interventions for men with co-occurring substance abuse and IPV with an emphasis on their roles as fathers.

METHOD

Sixty-nine men who participated in a randomized comparison study of a coordinated substance abuse and domestic violence treatment program (SADV) and Twelve Step Facilitation (TSF) provided information about whether they were fathers. Analysis of covariance was used to assess the impact of fatherhood on the outcomes of intimate partner violence and alcohol use during the 12 weeks of treatment.

RESULTS

There was a significant interaction between type of treatment (SADV vs. TSF) and fatherhood. SADV resulted in significantly less IPV and use of alcohol over the 12 weeks of treatment than TSF for men without children. There were no significant differences between SADV and TSF for men who were fathers.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Results indicate a need to further explore the role of fatherhood for men with co-occurring substance abuse and IPV and development of specialized treatments that may improve treatment outcomes for fathers.

The Mothers and Toddlers Program, an attachment-based parenting intervention for substance using women: post-treatment results from a randomized clinical pilot

This is a report of post-treatment findings from a completed randomized pilot study testing the preliminary efficacy of the Mothers and Toddlers Program (MTP), a 12 week attachment-based individual parenting therapy for mothers enrolled in substance abuse treatment and caring for children ages birth to 36 months. Forty-seven mothers were randomized to MTP versus the Parent Education Program (PE), a comparison intervention providing individual case management and child guidance brochures. At post-treatment, MTP mothers demonstrated better reflective functioning in the Parent Development Interview, representational coherence and sensitivity, and caregiving behavior than PE mothers. Partial support was also found for proposed mechanisms of change in the MTP model. Together, preliminary findings suggest that attachment-based interventions may be more effective than traditional parent training for enhancing relationships between substance using women and their young children.

Coercive sexual experiences, protective behavioral strategies, alcohol expectancies and consumption among male and female college students

Alcohol use and sexual assault on college campuses are highly prevalent and the focus of numerous prevention and intervention efforts. Our goals were to gain a greater understanding of the relationship between coercive sexual experiences, utilization of protective behavioral strategies and alcohol expectancies and consumption among male and female college students. We surveyed 370 college students regarding their past year experiences and found that 34% of women and 31% of men reported unwanted sexual contact, 6% of women and 13% of men reported engaging in sexually coercive behavior, and 4% of women and 9% of men reported experiencing both unwanted contact and engaging in sexually coercive behavior. Findings indicated students who experienced unwanted sexual contact reported significant differences in alcohol expectancies. More specifically, those who engaged in sexually coercive behaviors had significantly higher sex-related alcohol expectancies. In addition, recipients of unwanted contact reported higher alcohol consumption, used fewer protective strategies when drinking, and experienced more negative consequences due to their alcohol use. Results suggest that campus alcohol and sexual assault prevention efforts should include information on alcohol expectancies and use of protective strategies.

Drug abuse and responsible fathering: a comparative study of men enrolled in methadone maintenance treatment

AIM

Because very little is known about the parenting of drug-abusing men, this study was designed to document ways that drug abuse contributes to compromise of responsible fathering.

DESIGN, SETTING, PARTICIPANTS

Generalized linear models and data representing different dimensions of responsible fathering were used to clarify ways that the fathering of 106 men receiving methadone maintenance treatment differed from that of 118 men living in the same community with no history of alcohol or drug abuse.

MEASUREMENT

Men who enrolled in the study completed two structured interviews and a battery of five self-report measures selected to document current and historical dimensions of responsible fathering.

FINDINGS

When the opioid-dependent fathers were compared to the other fathers, there were significant differences in: (i) economic resources to support family formation; (ii) patterns of pair-bonding; (iii) patterns of procreation; and (iv) parenting behavior. When fathering of the youngest biological child was examined, the opioid-dependent fathers confirmed few differences in historical dimensions of fathering, but they reported significant differences in current dimensions reflecting: (i) constricted personal definitions of the fathering role; (ii) poorer relationships with biological mothers; (iii) less frequent residence with the child; (iv) less frequent provision of financial support; (v) less involvement in positive parenting; (vi) poorer appraisal of self as a father; and (vii) less satisfaction as a father.

CONCLUSIONS

The findings highlight ways that drug abuse contributes to compromise of responsible fathering, and they raise questions about ways that the drug abuse treatment system might better address parenting as a treatment issue for men.

Defining characteristics and potential consequences of caretaking burden among children living in urban poverty

Parentification of children has not been the focus of much empirical research. Consequently, this study was designed to explore the defining characteristics and potential consequences of caretaking burden in a sample of 356 children living in urban poverty. In a series of multivariate analyses, characteristics of the children, vocational-educational status of their mothers, and family structure correlated with caretaking burden more consistently than psychiatric, substance use, or personality problems in the mothers. Moreover, responsibility to care for mother, more so than responsibility for household chores or the care of siblings, consistently correlated with the psychosocial adjustment of the children. However, even the highest levels of caretaking burden were not consistently associated with clinically significant compromise of psychosocial adjustment.

Drug-abusing fathers: patterns of pair bonding, reproduction, and paternal involvement

Despite concerns about compromise of fathering as a public policy issue, very little is known about the status of drug-abusing men as parents. In this pilot study, 50 men enrolled in methadone maintenance treatment completed a structured research interview designed to generate basic information about patterns of pair bonding, reproduction, and paternal involvement. Descriptive analysis of these data highlighted a number of trends in the nature of fathering that, although at odds with popular stereotypes, were similar to trends noted in research conducted with other populations of disenfranchised men. Consistent with a developmental-ecological perspective on parenting, the findings suggest that historical and situational influences interact within this population to compromise socially responsible efforts to function as a parent. The results also raise questions about the extent to which public policy initiatives designed to promote more responsible fathering are reaching this population, and they highlight ways that the drug abuse treatment system might better support men interested in being a more effective parent.

Does assigning a representative payee reduce substance abuse?

BACKGROUND

Approximately 700,000 Social Security beneficiaries in the U.S. with psychiatric disabilities have been assigned a representative payee to manage their funds but it is unclear how those judged to need a payee differ from others and whether payee assignment improves clinical outcomes, especially substance abuse.

METHODS

Participants in this observational 12-month cohort study (n=1457) received SSI or SSDI and had serious mental illness. They were subsequently enrolled at eighteen community-based sites that provided Assertive Community Treatment. Social Security administrative records were used to determine whether a payee had been assigned.

RESULTS

At baseline, participants who were assigned a payee were more likely to have schizophrenia and had more severe clinician-rated drug and alcohol use than those not assigned a payee. In GEE models that adjusted for these and other potentially confounding covariates, participants assigned a payee between 4 and 12 months after program entry subsequently used significantly more psychiatric services than participants not assigned payees but showed no greater reduction in substance use.

CONCLUSIONS

Although substance use is associated with being assigned a payee, substance use does not decline substantially following payee assignment. Participants assigned payees made greater subsequent use of psychiatric services, suggesting the potential for benefit from payee assignment.

Improved adherence with contingency management

Contingency management (CM) based interventions that reinforce adherence to prescribed medications have shown promise in a variety of disadvantaged populations. Fifty-six participants with histories of illicit substance use who were prescribed antiretroviral medication but evidenced suboptimal adherence during a baseline assessment were randomly assigned to 16 weeks of weekly CM-based counseling or supportive counseling, followed by 16 additional weeks of data collection and adherence feedback to providers. The CM intervention involved review of data generated by electronic pill-bottle caps that record bottle opening (MEMS) and brief substance abuse counseling. CM participants were reinforced for MEMS-measured adherence with drawings from a bowl for prizes and bonus drawings for consecutive weeks of perfect adherence. Potential total earnings averaged $800. Mean MEMS-measured adherence to the reinforced medication increased from 61% at baseline to 76% during the 16-week treatment phase and was significantly increased relative to the supportive counseling group (p = 0.01). Furthermore, mean log-transformed viral load was significantly lower in the CM group. However, by the end of the 16-week follow-up phase, differences between groups in adherence and viral load were no longer significantly different. Proportions of positive urine toxicology tests did not differ significantly between the two groups at any phase. A brief CM-based intervention was associated with significantly higher adherence and lower viral loads. Future studies should evaluate methods to extend effects for longer term benefits.

Substance-abusing mothers and disruptions in child custody: an attachment perspective

Using an attachment framework, we examined (1) whether substance-abusing mothers' perceptions of how they were parented were related to the severity of their substance abuse and psychological maladjustment and (2) whether these two factors mediated the association between mothers' perceptions of how they were parented and their children's placement out of home. There were 108 mothers of 248 children who completed interviews upon admission to a methadone maintenance program for women. Measures included lifetime risk composite scores derived from the Addiction Severity Index, the Parental Bonding Instrument, and a demographics questionnaire. A multilevel modeling approach was used to model effects of the hierarchically organized data (e.g., children nested within families). Findings are consistent with an attachment perspective on parenting suggesting that the internal psychological processes of a parent play a critical role in the continuity of parenting.

Contingency management for smoking cessation in adolescent smokers

This pilot study evaluated the use of contingency management (CM) procedures in combination with cognitive-behavioral therapy (CBT) for smoking cessation in adolescents. Twenty-eight treatment-seeking adolescent smokers participated in a 1-month, school-based smoking cessation program and were randomly assigned to receive either CM with weekly CBT or CBT alone. In the CM+CBT group, biochemical verification of abstinence was obtained twice daily during the first 2 weeks, followed by daily appointments during the 3rd week and once every other day during the 4th week. Participants were monetarily reinforced for abstinence on an escalating magnitude schedule with a reset contingency. At the end of 1 week and 1 month of treatment, abstinence verified using quantitative urine cotinine levels was higher in participants in the CM+CBT group (1 week: 76.7%; 1 month: 53.0%) when compared with the CBT-alone group (1 week: 7.2%; 4 weeks: 0%). These preliminary results provide a strong initial signal supporting the utility of CM techniques for smoking cessation in adolescents and demonstrate the feasibility of implementing such a program in a school setting.

Patterns and correlates of substance use among affluent, suburban high school students

Despite ongoing concern about substance use during adolescence, very little is known about alcohol and drug use among teens living in affluent social settings. In this longitudinal study, cluster analysis was used to characterize patterns of substance use and change in other dimensions of psychosocial adjustment within a cohort of 292 high school students (54% girls) living in an affluent, suburban community. When compared with a cluster of students reporting minimal use, clusters reporting escalating, declining, and persistently high use consistently demonstrated relatively poorer psychosocial adjustment. Moreover, other dimensions of psychosocial adjustment remained relatively stable despite changes in substance use, and there were relations involving substance use and other aspects of psychosocial adjustment that may be specific to this social setting. The findings highlight the need for preventive intervention grounded in a clear understanding of developmental process occurring within populations of affluent, suburban teens.

Effect of Social Security payments on substance abuse in a homeless mentally ill cohort

OBJECTIVES

To determine whether receipt of social supplemental security income (SSI) or Social Security disability income (SSDI) disability payments is associated with increased drug and alcohol use.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from 6,199 participants in the Access to Community Care and Effective Social Supports and Services demonstration for the homeless mentally ill.

DESIGN

Observational, 12-month, cohort study completed over 4 years. Substance abuse and other outcomes were compared between the participants who did not receive SSI or SSDI during the 12-month study, those newly awarded benefits, and those without benefits throughout the 12 months.

DATA COLLECTION METHODS

Social Security administrative records were used to corroborate Social Security benefit status. Drug and alcohol use were measured by self-report and clinician ratings.

PRINCIPAL FINDINGS

Participants who did not receive benefits significantly reduced their substance use over time. In generalized estimating equations models that adjusted for potentially confounding covariates, participants who newly received Social Security benefits showed no greater drug use than those without benefits but had significantly more days housed and fewer days employed. Participants whose benefits antedated the demonstration and continued during the 12 months had more clinician-rated drug use over time than those without benefits.

CONCLUSIONS

In this vulnerable population, participants with newly awarded benefits did not have any different drug use changes than those without benefits, and had relatively more days housed. The hypothesis that Social Security benefits facilitate drug use was not supported by longitudinal data in this high-risk population.

How early bonding, depression, illicit drug use, and perceived support work together to influence drug-dependent mothers' caregiving

In this study, the authors used an attachment framework to examine how drug-dependent mothers' early bonding experience, depression, illicit drug use, and perceived support work together to influence the family environment. The authors hypothesized that (a) depression and drug use function as proxies for a stronger risk factor, the perceived absence of support available in everyday life, and (b) associations between mothers' early bonding experience and family environment are mediated by perceptions of support and nurture available in everyday life. The authors used a "building block" analytic approach and data collected from 125 mothers enrolled in methadone maintenance to test hypotheses. Both hypotheses were confirmed for 1 outcome, family adaptability. For the 2nd outcome, family cohesion, only perceived support was a significant predictor. Although preliminary, the findings suggest that perceptions of relationships in everyday life play a critical role in the etiology of drug-dependent mothers' parenting.

Looking for poppa: parenting status of men versus women seeking drug abuse treatment

This survey of individuals seeking methadone maintenance treatment was pursued to document the parenting status of drug-dependent men and clarify ways their status as parents differs from that of drug-dependent women. Data concerning demographic characteristics, drug abuse history, and parenting status were systematically coded from the medical records of 362 men and 162 women seeking methadone maintenance treatment during a 12-month period. Analysis of parenting status by gender indicated that, although a greater proportion of women were the parent of at least one biological child, there were actually more fathers than mothers within the cohort. Among the parents, fathers were more likely to have been abusing opioids when they first became a parent, and they were more likely to be living away from their children. There were no significant gender differences in the number of children or the average age of children. The results suggested that fathering may be an important, but largely neglected, treatment issue for drug-abusing men.

Interpersonal maladjustment as predictor of mothers’ response to a relational parenting intervention

In previous work, Luthar and Suchman (2000, Development & Psychopathology, 12, 235) reported results of a randomized clinical trial testing the efficacy of the Relational Psychotherapy Mothers' Group (RPMG) for methadone-maintained mothers. In this extension, we examined maternal interpersonal maladjustment as a predictor of differential response to RPMG versus standard drug counseling (DC). We predicted that RPMG mothers with high levels of interpersonal maladjustment would improve on parent-child relationship indices, whereas DC mothers with high levels of interpersonal maladjustment would show no improvement. Fifty-two mothers enrolled in the study completed baseline, post-treatment and 6-month followup assessments and a subset of 24 "target" children between the ages of 7 and 16 completed measures on mothers' parenting. As predicted, results of hierarchical regression analyses indicated moderate interpersonal maladjustment x treatment interaction effects for all parenting outcomes at post-treatment and for a subset of outcomes at followup. Plotted interactions confirmed predictions that, as maternal interpersonal maladjustment increased, parenting problems improved for RPMG mothers and remained the same or worsened for DC mothers. Results indicate the potential value of interpersonally oriented interventions for substance-abusing mothers and their children.

Initial appointment nonattendance in child and family mental health clinics

Current medical, psychiatric, and nursing sources were examined for literature concerning the problem of initial appointment non attendance at child and family mental health clinics. The factors proposed to underlie missed initial appointments were reviewed and found to be both contradictory and inconsistent. Interventions designed to increase attendance were considered. These interventions were found to significantly increase attendance consistently. However, it is noted that the research on underlying factors is not utilized in structuring these interventions. Suggestions for future research to address this problem are offered.

Substance abuse and fathering: adding poppa to the research agenda

Although a number of socioeconomic forces have converged across cultures to make fathering one of the more prominent social issues of the new millennium, the status of substance-abusing men as fathers is rarely acknowledged in the conceptualization of public policy, service delivery or research focusing on the adverse consequences of drug and alcohol abuse. In this commentary, the authors call for the substance abuse research community to expand understanding of fathering occurring across cultures in the context of chronic substance abuse. Building upon research being undertaken with other populations of fathers, the authors argue there is need to clarify (a) the number of substance-abusing fathers, (b) patterns of reproduction among substance-abusing men, (c) ways in which substance abuse contributes to compromise of fathering, (d) ways in which compromise of fathering contributes to psychological distress in substance-abusing men, (e) ways in which compromise of fathering affects developmental outcomes for children, and (f) ways in which clinical and preventive intervention might be used to minimize the harm associated with paternal substance abuse.

Tell them you love them because you never know when things could change: voices of adolescents living with HIV-positive mothers

This study analyzed the qualitative and quantitative responses of 60 minority teens affected by HIV. Relationships between adolescents' reports of: (1) feeling different, (2) having secrets, (3) worrying, and (4) caretaking were revealed. Six themes emerged from the content analysis of qualitative data that reflect how these adolescents have been affected by HIV: (1) core assumptions about life, (2) fearful anticipation of the death, (3) stigma and isolation, (4) current and future losses, (5) family role reassignment, and (6) lack of resources. Group treatment is presented as an effective method of intervention for adolescents living with an HIV-positive mother.

Fathers with serious mental illnesses: a neglected group

In recent years, policy makers, researchers, and practitioners alike have come to recognize how the traditional emphasis on mothers has overshadowed the equally critical contribution of fathers to child development and family life. In spite of this growing recognition of the importance of fathers, the need to better understand and support fathers with serious mental illnesses (SMI) has received little attention within mental health, public welfare, child protection, or criminal justice systems. In an effort to counter the continuing neglect of fathers with SMI, this paper provides an overview of the scant existing research focusing on fathers with SMI and sets forth a series of recommendations highlighting the need for greater inclusion of fathers in future research and ways to support men with SMI in their role as parents.