Engaging mothers with substance use issues and their children in early intervention: Understanding use of service and outcomes

Programs and practices that support pregnant people who use drugs' access to sexual and reproductive health care in Canada: a scoping review

BACKGROUND

Pregnant people who use unregulated drugs (PPWUD) are at high risk of health complications yet experience a range of barriers to sexual and reproductive health care. Given that improving maternal health and access to reproductive health care are key targets underpinning the Sustainable Development Goals (SDG), there is an urgent need to improve access to appropriate supports and services for this population. Little is known about what programs and practices exist to support PPWUD's access to sexual and reproductive health care. This scoping review aimed to identify the available literature on these programs and practices in Canada.

METHODS

A scoping review was conducted using JBI methodology and reported using PRISMA guidelines. Scholarly databases and grey literature sources were searched to identify literature published between 2016-2023 in English or French that discussed, defined, conceptualised, or evaluated programs and practices that support PPWUD's access to sexual and reproductive health care in Canada. Identified literature was screened using Covidence. Data were extracted from included texts, then analysed descriptively. Frequencies and key concepts were reported.

RESULTS

A total of 71 articles were included, most of which were grey literature. Of the total, 46 unique programs were identified, as well as several useful practices. Most programs were in urban centres in Western Canada, and most programs offered holistic 'wrap-around services.' Several programs delivered these services on-site or as 'drop-in' programs with the support of staff with lived/living experience of substance use. Most frequent program outcomes included keeping parents and children together, improving connection to other services, and reducing substance use harms. Noted helpful practices included non-judgmental care and the use of harm-reduction strategies.

CONCLUSIONS

Several programs and practices that support PPWUD exist in Canada, though few focus exclusively on sexual and reproductive health. There remain opportunities to improve access to programs, including expanding geographic availability and range of services. The review has clinical application by providing an overview of available programs that may support clinicians in identifying services for PPWUD. Future research should consider client perspectives and experiences of these programs.

REVIEW REGISTRATION NUMBER

Open Science Framework https://osf.io/5y64j .

A comparative effectiveness study of the breaking the cycle and Maxxine Wright intervention programs for substance-involved mothers and their children: study protocol

BACKGROUND

Children of substance-involved mothers are at especially high risk for exposure to adverse childhood experiences (ACEs) and poor mental health and development. Early interventions that support mothers, children, and the mother-child relationship have the greatest potential to reduce exposure to early adversity and the mental health problems associated with these exposures. Currently, there is a lack of evidence from the real-world setting demonstrating effectiveness and return on investment for intervention programs that focus on the mother-child relationship in children of substance-involved mothers.

METHODS

One hundred substance-involved pregnant and/or parenting women with children between the ages of 0-6 years old will be recruited through the Breaking the Cycle and Maxxine Wright intervention programs, in Toronto, Ontario, Canada and Surrey, British Columbia, Canada, respectively. Children's socioemotional development and exposure to risk and protective factors, mothers' mental health and history of ACEs, and mother-child relationship quality will be assessed in both intervention programs. Assessments will occur at three time points: pre-intervention, 12-, and 24-months after engagement in the intervention program.

DISCUSSION

There is a pressing need to identify interventions that promote the mental health of infants and young children exposed to early adversity. Bringing together an inter-disciplinary research team and community partners, this study aligns with national strategies to establish strong evidence for infant mental health interventions that reduce child exposure to ACEs and support the mother-child relationship. This study was registered with clinicaltrials.gov (NCT05768815) on March 14, 2023.

Relational practice in health, education, criminal justice, and social care: a scoping review

BACKGROUND

Establishing and maintaining relationships and ways of connecting and being with others is an important component of health and wellbeing. Harnessing the relational within caring, supportive, educational, or carceral settings as a systems response has been referred to as relational practice. Practitioners, people with lived experience, academics and policy makers, do not yet share a well-defined common understanding of relational practice. Consequently, there is potential for interdisciplinary and interagency miscommunication, as well as the risk of policy and practice being increasingly disconnected. Comprehensive reviews are needed to support the development of a coherent shared understanding of relational practice.

METHOD

This study uses a scoping review design providing a scope and synthesis of extant literature relating to relational practice focussing on organisational and systemic practice. The review aimed to map how relational practice is used, defined and understood across health, criminal justice, education and social work, noting any impacts and benefits reported. Searches were conducted on 8 bibliographic databases on 27 October 2021. English language articles were included that involve/discuss practice and/or intervention/s that prioritise interpersonal relationships in service provision, in both external (organisational contexts) and internal (how this is received by workers and service users) aspects.

RESULTS

A total of 8010 relevant articles were identified, of which 158 met the eligibility criteria and were included in the synthesis. Most were opinion-based or theoretical argument papers (n = 61, 38.60%), with 6 (3.80%) critical or narrative reviews. A further 27 (17.09%) were categorised as case studies, focussing on explaining relational practice being used in an organisation or a specific intervention and its components, rather than conducting an evaluation or examination of the effectiveness of the service, with only 11 including any empirical data. Of the included empirical studies, 45 were qualitative, 6 were quantitative, and 9 mixed methods studies. There were differences in the use of terminology and definitions of relational practice within and across sectors.

CONCLUSION

Although there may be implicit knowledge of what relational practice is the research field lacks coherent and comprehensive models. Despite definitional ambiguities, a number of benefits are attributed to relational practices.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021295958.

Parental health in the context of public family care proceedings: A scoping review of evidence and interventions

BACKGROUND

Child protective services (CPS), or their equivalent, have statutory power to remove children from birth parents in instances of child abuse, neglect, or concerns around parenting capacity via public family care proceedings. Parents who have children subject to proceedings, 'birth parents', often have complex health and social care needs.

OBJECTIVE

We aimed to review what is known about the health needs of birth parents and the interventions implemented to support these health needs.

METHODS

We searched PubMed, Scopus, and grey literature using a systematic strategy of key concepts "health", "care proceedings", and "parents". We included all publications in English that reported parental health in the context of care proceedings from the 1st of January 2000 to the 1st of March 2021.

RESULTS

Included studies (n = 61) reported on maternal health (57 %) or the health of both parents (40 %), with only one study reporting on fathers alone. We conceptually categorised parental health need (n = 41) into i) mental health, ii) physical health, iii) substance misuse, iv) developmental disorders, and v) reproductive health. Health inequities and poor access to services were described across all categories, with longstanding issues often pre-dating proceedings or the child's birth. All interventions supporting parental health (n = 20) were targeted at mothers, with some supporting fathers (n = 8), formally or informally. We grouped similar interventions into three types: alternative family courts, wrap-around services, and specialist advocacy/peer support.

CONCLUSIONS

Parents who have children subject to care proceedings have complex health needs that pre-date CPS concerns. The studies included in our review strongly suggest that health issues are exacerbated by child removal, triggering deteriorations in mental health, poor antenatal health for subsequent pregnancies, and avoidable mortality. Findings highlight the need for targeted and timely intervention for parents to improve whole-family outcomes. There are models that have been designed, implemented, and tested using relationship-based, trauma-informed, multidisciplinary, family-focused, and long-term approaches.

The CPS Workers' Child Removal Decision in Cases of Domestic and Witnessed Violence

This study aimed to explore maternal and paternal risks and protective factors that may influence the Child Protection Service (CPS) workers' child removal decision in case of domestic and witnessed violence. In all, 218 case reports of Italian CPSs were retrospectively analyzed through the Protocol of Risk and Protective Factors. The sample was then split up into two groups on the basis of the CPS professionals' placement decision after the investigation (child removal decision versus parents support and monitoring intervention). Two statistical approaches were used to identify the patterns of risk and protective factors associated with maternal and paternal assessments: logistic regression models and decision tree analysis. Results showed that mothers who are victims of Intimate Partner Violence experienced the child removal in about half of the cases, while fathers showed a higher removal rate. Differences emerged between mothers' and fathers' risk profiles, suggesting that workers attributed a different weight to some factors depending on whether they concerned the mother or the father. Only the proximal risk factor poor empathy skills was significant for both mothers and fathers. For the mothers' group, one of the most important factors was the presence of direct forms of child maltreatment in addition to witnessed violence, while for fathers' group the drug abuse emerged a crucial relevant proximal risk factor.

Outpatient substance abuse treatment completion rates for racial-ethnic minorities during the Great Recession

There has been minimal research linking the effects on racial-ethnic minorities' health outcomes, particularly research focused on racial-ethnic minorities seeking outpatient substance abuse treatment in the United States. The Great Recession from December 2007 to June 2009 in the United States provides the backdrop against the completion of substance abuse treatments among racial-ethnic minorities that may be associated with the impacts on users' social realities. We utilized data from the 2006-2011 Treatment Episode Datasets-Discharge (TEDS-D) dataset which collects data on outpatient substance abuse treatment institutions throughout the United States. The substance abuse treatment completion rates were higher prior to the Great Recession and lower following the Great Recession. Hispanics were more likely than non-Hispanic whites to complete substance abuse treatment, while other minority groups such as Non-Hispanic Blacks, were less likely to do so. Clients in the Northeast and West regions were more likely to successfully complete substance abuse treatment than those in the South. These findings have implications for impacting outpatient substance abuse treatment completion rates following the Great Recession to reduce racial-ethnic disparities which were impacted by region. Even amid an economic recession, treatment for substance abuse should continue to be a top concern.

Parental substance use and home visiting programs: Implementation considerations for relationship-based treatment

Home visiting programs can provide critical support to mothers in recovery from substance use disorders (SUDs) and young children prenatally exposed to substances. However, families impacted by maternal SUDs may not benefit from traditional child-focused developmental home visiting services as much as families not impacted by SUDs, suggesting the need to adjust service provision for this population. Given the need to implement tailored services within home visiting programs for families impacted by SUDs, we sought to investigate the implementation barriers and facilitators to inform future integration of a relationship-based parenting intervention developed specifically for parents with SUDs (Mothering from the Inside Out) into home visiting programs. We conducted nine interviews and five focus groups with a racially diverse sample (N = 38) of parents and providers delivering services for families affected by SUDs in the USA. Qualitative content analysis yielded three most prominent themes related to separate implementation domains and their associated barriers and facilitators: (1) engagement, (2) training, and (3) sustainability. We concluded that the home visiting setting may mitigate the logistical barriers to access for families affected by SUDs, whereas relationship-based services may mitigate the emotional barriers that parents with SUDs experience when referred to home visiting programs.

Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches

Alcohol is legalized and used for a variety of reasons, including socially or as self-medication for trauma in the absence of accessible and safe supports. Trauma-informed approaches can help address the root causes of alcohol use, as well as the stigma around women's alcohol use during pregnancy. However, it is unclear how these approaches are used in contexts where pregnant and/or parenting women access care. Our objective was to synthesize existing literature and identify promising trauma-informed approaches to working with pregnant and/or parenting women who use alcohol. A multidisciplinary team of scholars with complementary expertise worked collaboratively to conduct a rigorous scoping review. All screening, extraction, and analysis was independently conducted by at least two authors before any differences were discussed and resolved through team consensus. The Joanna Briggs Institute method was used to map existing evidence from peer-reviewed articles found in PubMed, CINAHL, PsycINFO, Social Work Abstracts, and Web of Science. Data were extracted to describe study demographics, articulate trauma-informed principles in practice, and gather practice recommendations. Thirty-six studies, mostly from the United States and Canada, were included for analysis. Studies reported on findings of trauma-informed practice in different models of care, including live-in treatment centers, case coordination/management, integrated and wraparound supports, and outreach-for pregnant women, mothers, or both. We report on how the following four principles of trauma-informed practices were applied and articulated in the included studies: (1) trauma awareness; (2) safety and trustworthiness; (3) choice, collaboration, and connection; and (4) strengths-based approach and skill building. This review advances and highlights the importance of understanding trauma and applying trauma-informed practice and principles to better support women who use alcohol to reduce the risk of alcohol-exposed pregnancies. Relationships and trust are central to trauma-informed care. Moreover, when applying trauma-informed practices with pregnant and parenting women who use alcohol, we must consider the unique stigma attached to alcohol use.

Qualitative description of outreach and engagement in perinatal substance treatment in Finland

BACKGROUND

Women with perinatal substance problems experience a multitude of barriers to care. They have specific early intervention needs, they endure societal stigma, and both substances and mental health issues influence the way they navigate within support and treatment systems. Early interventions for women with perinatal substance problems are underresearched contexts. The aim of the study is to describe building relationships and engagement within an outreach and low threshold service encounter tailored for pregnant women with SUD (substance use disorder).

METHODS

The data consist of online written narratives from 11 workers involved in the program and feedback from 504 families in the recovery process comprising 228 open-ended answers. The data were analyzed with a thematic analysis.

RESULTS

The programs are characterized by flexibility and the implementation of inclusive ways to approach families. The themes for enhancing relationships and engagement within outreach and low threshold programs are Acceptance and attitude: a sensitive approach of approval; flexibility within strictness to allow for diversity and individuality; availability and space to ensure a trustful atmosphere; negotiating via doing to build connections; and everyday life changes: imagining recovery. The themes represent the need of being available, focusing on the worker's attitudes and building connections by doing together, and visioning recovery together.

CONCLUSIONS

The study results can add to the understanding of SUD outreach and low threshold work during pregnancy. The elements described in this study need further theoretical development, research and critical assessment. Building relationships during pregnancy were characterized by connecting within everyday life situations and supporting the development of an attachment relationship between the baby and the parents. To promote recovery, a comprehensive approach in which substance-related issues and mental health conditions are interconnected can be favored. Engaging early on during pregnancy might enhance success during future rehabilitation.

Wraparound programmes for pregnant and parenting women with substance use concerns in Canada: Partnerships are essential

Wraparound programmes, wherein multiple services are offered at one location, are effective in engaging pregnant or parenting women experiencing substance use and other complex challenges while also addressing gaps in services between the health, child welfare and addictions fields. Evaluations of these programmes have demonstrated positive outcomes; nevertheless, few studies have focused on how programmes' cross-sectoral partnerships are structured and the difference these partnerships make. Drawing on the Co-Creating Evidence study, a three-year Canadian evaluation of eight multi-service programmes in six provinces, this article examines the partnerships that make wraparound service delivery possible. The study used a mixed-methods design involving interviews, questionnaires, output and de-identified client data; this article reports on qualitative findings only. Sixty service partners and 108 programme staff were interviewed in 2018 and 2019. Qualitative data analysis techniques were applied; NVivo12 software (QRS International, Melbourne, Australia) was utilised to facilitate the analyses. In terms of the programmes' partnership characteristics, overall, programmes more commonly formed partnerships with child welfare, health services (e.g. primary care, public health and perinatal care) and specialised health services such as mental health services, maternal addictions and Opioid Agonist Therapy. The programmes had fewer partnerships with housing, income assistance, Indigenous cultural programming, infant development and legal services. Key benefits of partnerships included: clients' improved access to health and social care, addressing social determinants of health; partners' increased knowledge about the significance of trauma in relation to women's substance use; improved child welfare outcomes and strengthened cultural safety and (re)connection. Key challenges included: tensions between partners regarding differing perceptions, mandates and responsibilities; personal differences and systemic barriers. Lastly, by means of steady dialogue and collaboration, partners increased their appreciation and use of the trauma-informed, harm reduction approaches that are central to wraparound programmes.

Residential substance use treatment outcomes for pregnant and postpartum women: Distinct patterns for women enrolled before versus during the COVID-19 pandemic

Introduction

Substance use among pregnant and postpartum women (PPW) is a serious public health concern. The COVID‐19 pandemic has exacerbated substance use among the general population including pregnant women, and disrupted operations for substance use treatment centers. Little is known about the outcomes of substance use treatment for PPW before and during the COVID‐19 pandemic.

Method

Data from a longitudinal program evaluation were analyzed to examine outcomes among 136 PPW participating in a residential SUD treatment program, and to explore differences in treatment outcomes for women who enrolled in services before versus during the COVID‐19 pandemic. Analyses were used to test the significance of change from treatment intake to 6‐month post‐intake on assessments of substance use, mental health symptoms, and functioning collected to evaluate the Healthy Families Program (HFP), a comprehensive program for PPW located within a gender‐specific SUD treatment facility in the United States.

Results

Results indicated that from treatment intake to follow‐up assessment, clients self‐reported statistically significant improvements in family functioning and daily functioning as well as reduced days of substance use. Notably, the rate of treatment intakes declined during the COVID‐19 pandemic. In separate analyses by subgroup, mental health indicators showed improvements only for clients engaged in treatment before the COVID‐19 pandemic and not for clients served during the COVID‐19 pandemic, but substance use decreased significantly for both pre‐pandemic and pandemic enrollees.

Conclusion

Specialized treatment considerations and implications for PPW are discussed, including a need for added emphasis on co‐occurring mental health symptoms and family system stress during a pandemic, and the role of nurses in identifying and addressing these concerns. Additionally, potential relapse prevention efforts during COVID‐19 for PPW with substance use disorders are examined.

Clinical Relevance

The present research continues to highlight the importance of specialized treatment programming for PPW with SUDs as well as the potential need for additional recovery support mechanisms to be utilized during the COVID‐19 pandemic.

Treatment providers' perspectives on a gender-responsive approach in alcohol and drug treatment for women in Belgium

BACKGROUND

Gender inequity is a pervasive challenge to health equity on a global scale, and research shows the impact of sex and gender on substance use regarding for example epidemiology, treatment needs, treatment admission and treatment outcomes. The gender-transformative approach to action and health indicates that health interventions may maintain, exacerbate or reduce gender-related health inequalities, depending on the degree and quality of gender-responsiveness within the programme or policy. However, research shows a lack of gender-responsive initiatives in the alcohol and drug addiction field.

AIMS

The purpose of this study is to explore in depth how alcohol and drug treatment can be made more sensitive to female users' treatment needs from the perspective of service providers. Consequently, study findings can inform the development of gender-responsive treatment options and aid to a deeper understanding of how these trends are designated on the continuum of approaches to action and health in the alcohol and drug field.

METHODS

Four focus groups were organized across different regions in Belgium with a total of 43 participants, including service providers, policy makers and women who use(d) drugs.

RESULTS

The perspective of the participants on substance use prevention and treatment for female users incorporates some crucial gender-specific and gender-transformative features. Next to implementing mother-child options, a holistic approach, experts by experience and empowering women in treatment, professionals report the relevance of awareness raising campaigns targeting all levels and sectors in society. Also, recurring attention was given to the role of men in the narratives of female users.

CONCLUSION

Study findings show that the field of alcohol and drug prevention and treatment is being looked at through the lens of gender-responsiveness. However, to achieve improvement in the lives of both women and men, and hence creating more equal chances and opportunities in substance abuse treatment, the gender-transformative approach in addiction care needs to be further explored, criticized and established in practice and future research.

Improving engagement with services to prevent Sudden Unexpected Death in Infancy (SUDI) in families with children at risk of significant harm: A systematic review of evidence

This paper reports part of a wider systematic review commissioned by the English National Safeguarding Panel on Sudden Unexpected Death in Infancy (SUDI). The wider review covered three areas: interventions to improve safer sleep practices in high-risk families, interventions to improve engagement with services and decision making by parents at high risk of SUDI about infant sleep environments. Here, we report the qualitative and quantitative studies reviewed under the engagement strand. Parental engagement is understood to be a multidimensional task for health and social care professionals comprising attitudinal, relational and behavioural components. Following a PROSPERO registered systematic review synthesizing the three strands outlined, 28 papers were found to be relevant in the review of interventions to improve engagement with services in families with children at risk of significant harm through abuse or neglect. No studies were found that specifically focused on engagement of families at high risk for SUDI, so these wider engagement studies were included. The different types of intervention reported in the included studies are described under two broad themes: Enablers (including parental motivation and working with families) and Barriers. Given the focus in the studies on interventions that support parental engagement, the Enablers theme is more extensive than the Barriers reported although all studies noted well-understood barriers. The evidence underpinning these interventions and approaches are reviewed in this paper. We conclude that effective engagement is facilitated by experienced professionals given time to develop supportive non-judgemental relationships with families in their homes, working long-term, linking with communities and other services. While these conclusions have been drawn from wider studies aimed at reducing child maltreatment, we emphasize lessons to be drawn for SUDI prevention work with families with children at risk of significant harm.

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 good mother": Impact of motherhood identity on women's substance use and engagement in treatment across the lifespan

BACKGROUND

Women are underrepresented in substance use disorder (SUD) treatment. Interpersonal and structural factors affect women's access to SUD treatment, but limited research evaluates how motherhood is a potential barrier and facilitator to engagement in SUD treatment. We focus on women from young to middle adulthood, and capture women's identities as mothers, caretakers, and grandmothers, outside of pregnancy and the postpartum period.

METHODS

Study staff conducted twenty qualitative interviews with women in SUD treatment to assess experiences with SUD treatment, in which motherhood emerged as a key theme. Twelve women then participated in four focus groups centered on motherhood. The study audio-recorded and transcribed interviews, and two independent authors analyzed interviews, followed by group consensus.

RESULTS

Most women identified their children and responsibilities as mothers and caretakers as important motivators to accessing SUD treatment. Motherhood was also a barrier to treatment, in that women feared losing child custody by disclosing substance use and few residential programs accommodate women with children. Multiple women expressed guilt about their substance use, sensing that it contributed to perceived abandonment or separation from their children. Reunification was important to SUD recovery.

CONCLUSION

Women with SUD who are mothers experience specific barriers to treatment engagement and recovery. Women need SUD treatment programs that address these interpersonal and structural factors across the lifespan.

Developing a model of care for substance use in pregnancy and parenting services, Sydney, Australia: Service provider perspectives

INTRODUCTION

The absence of a clear model of care for services supporting pregnant women and mothers with substance use disorders has impeded opportunities to build an evidence base for the effectiveness of these services. Previous research has typically focused on the needs of pregnant women or mothers, as two distinct groups. This paper explores service providers' perceptions of key components of a model of care, extending from perinatal care to community-based support for up to 17 years post-delivery. A model of care is outlined and feasibility factors affecting implementation are highlighted.

METHODS

Qualitative methods were adopted as a first step to informing development of the model of care. Semi-structured in-depth interviews were conducted with thirty-eight staff providing a range of substance use in pregnancy and parenting services (SUPPS) in hospital and community-based agencies, in a metropolitan health district in Sydney, Australia. Interview data was entered into NVivo and analysed using constant comparative methods.

RESULTS

Guiding principles for the model of care included integrated care, harm reduction and person-centredness. Practice approaches integral to the model of care were promoting engagement with women, flexible service provision, trauma-informed care, and continuity of care. Feasibility factors influencing implementation of the model of care included fragmentation or siloing of the service network and workforce sustainability.

CONCLUSIONS

A harm reduction approach was crucial for promoting engagement of women with SUPPS, particularly child protection services. A greater focus on providing ongoing community-based support for mothers also has the potential to achieve sustainable positive outcomes for women and children. Implementation of the SUPPS model of care could be undermined by threats to integration of service delivery and continuity of care. Further research is needed to explore consumer perspectives and inform the model of care as a framework for evaluation.

Modernizing Perinatal Substance Use Management

The increase in prescription and illicit opioid use since 2000 has become an urgent public health crisis. While the opioid epidemic spans racial, regional, and socioeconomic divides, women have surfaced as one demographic affected by opioid use and related sequelae. Certain federal and state regulations, secondary to the Child Abuse Prevention and Treatment Act, strip pregnant women with opioid use disorders of the ability to engage autonomously with their health care clinician while simultaneously impeding their ability to achieve and sustain recovery. The purpose of this article is to explore current health policy that impacts pregnant women who use opioids. Recommendations to improve care, broadly, will be highlighted to include access to contraceptive services, universal screening for perinatal substance use, and access to appropriate treatment strategies. Policy modifications to facilitate these recommendations are discussed. The Centers for Disease Control and Prevention Policy Analytical Framework was utilized to derive recommendations. The recommendations are relevant to advanced practice registered nurses and midwives who have the potential to treat substance use in women, to women's health and pediatric registered nurses, and to nursing administrators who are involved in decision-making in obstetric and pediatric settings.

Establishing clinically and theoretically grounded cross-domain cumulative risk and protection scores in sibling groups exposed prenatally to substances

BACKGROUND

Prenatal substance exposure is associated with neurodevelopmental deficits. Deficits are exacerbated by cumulative risks yet attenuated by cumulative protective factors. Cross-domain relative to intra-domain risk exposure presents more neurodevelopmental challenges. Cumulative risk and protection scores must be clinically and theoretically grounded, with cross-domain considerations.

OBJECTIVES

1) Create clinically and theoretically grounded, cross-domain cumulative risk and protection scores; 2) Describe the benefits of our methodological approach.

PARTICIPANTS & SETTING

This study included three sibling groups (N = 8) at Mothercraft's Breaking the Cycle, a child maltreatment prevention and early intervention program for substance using mothers and their children.

METHOD

We outlined the process of establishing clinically and theoretically grounded, cross-domain cumulative risk and protection scores. Total and cross-domain cumulative risk and protection percentages, and the balance between domains of risk and protection, were explored.

RESULTS

Clinically and theoretically grounded, cross-domain cumulative risk and protection scores were established. Total percentages were reported. Cross-domain profiles of cumulative risk and protection, and the number of significant domains of risk relative to protection, were reported. The cross-domain profiles facilitated consideration of intra- and inter-domain risk and protection within and between sibling groups.

CONCLUSIONS

Emerging patterns indicate the importance of establishing cumulative risk and protection scores that are: 1) clinically and theoretically grounded, 2) cross-domain, and 3) encompass cumulative protection and risk. In understanding profiles of risk and protection, we can inform evidence-based early interventions that address: 1) high-risk children, 2) the full range of risks, 3) vulnerable domains, and 4) protective factors.

Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients' perspectives on wraparound programming

BACKGROUND

In Canada, several community-based, multi-service programs aimed at reaching vulnerable pregnant or parenting women with substance use and complex issues have emerged. These programs offer basic needs and social supports along with perinatal, primary, and mental health care, as well as substance use services. Evaluations of these 'one-stop' programs have demonstrated positive outcomes; nevertheless, few published studies have focused on how these programs are structured, on their cross-sectoral partnerships, and on clients' perceptions of their services.

METHODS

The Co-Creating Evidence (CCE) project was a three-year evaluation of eight multi-service programs located in six Canadian jurisdictions. The study used a mixed-methods design involving semi-structured interviews, questionnaires, output data, and de-identified client data. This article focuses on qualitative interviews undertaken with 125 clients during the first round of site visits, supplemented by interview data with program staff and service partners.

RESULTS

Each of the programs in the CCE study employs a multi-service model that both reflects a wrap-around approach to care and is intentionally geared to removing barriers to accessing services. The programs are either operated by a health authority (n = 4) or by a community-based agency (n = 4). The programs' focus on the social determinants of health, and their provision of primary, prenatal, perinatal and mental health care services is essential; similarly, on-site substance use and trauma/violence related services is pivotal. Further, programs' support in relation to women's child welfare issues promotes collaboration, common understanding of expectations, and helps to prevent child/infant removals.

CONCLUSIONS

The programs involved in the Co-Creating Evidence study have impressively blended social and primary care and prenatal care. Their success in respectfully and flexibly responding to women's diverse needs, interests and readiness, within a community-based, wraparound service delivery model paves the way for others offering pre- and postnatal programming.

Parenting Interventions for Mothers With Problematic Substance Use: A Systematic Review of Research and Community Practice

Women with problematic substance use are frequently referred to interventions to promote positive parenting. Parenting interventions that attend to the unique risks faced by this population may enhance engagement and outcomes. While reviews of extant parenting interventions in the research literature have been undertaken, no studies have examined parenting interventions being implemented in community practice and the extent to which these are informed by current research. We systematically compared parenting interventions offered in 12 maternal substance use treatment programs in one Canadian province with those described in the research literature (K = 21). Few parenting interventions were replicated, either within or across the two samples. However, parenting interventions within both samples were largely similar in their objectives. Across both research and community samples, approximately half of the interventions were developed or adapted for a problematic substance use population. Parenting knowledge, psychosocial risk, and maternal emotional regulation were most commonly addressed. Risks pertaining to the impact of drug craving and substance-related changes in neurobiology associted with parenting were less commonly addressed. Findings highlight current strengths and limitations of parenting interventions within research and community settings, with recommendations offered for future research and knowledge translation.

Gender Norms, Roles and Relations and Cannabis-Use Patterns: A Scoping Review

Currently, boys and men use cannabis at higher rates than girls and women, but the gender gap is narrowing. With the legalization of recreational cannabis use in Canada and in multiple US states, these trends call for urgent attention to the need to consider how gender norms, roles and relations influence patterns of cannabis use to inform health promotion and prevention responses. Based on a scoping review on sex, gender and cannabis use, this article consolidates existing evidence from the academic literature on how gender norms, roles and relations impact cannabis-use patterns. Evidence is reviewed on: adherence to dominant masculine and feminine norms and cannabis-use patterns among adolescents and young adults, and how prevailing norms can be both reinstated or reimagined through cannabis use; gendered social dynamics in cannabis-use settings; and the impact of gender roles and relations on cannabis use among young adults of diverse sexual orientations and gender identities. Findings from the review are compared and contrasted with evidence on gender norms, roles and relations in the context of alcohol and tobacco use. Recommendations for integrating gender transformative principles in health promotion and prevention responses to cannabis use are provided.

The best possible start: A qualitative study on the experiences of parents of young children with or at risk for fetal alcohol spectrum disorders

BACKGROUND

The developmental outcomes and life course trajectories of young children with or at-risk for fetal alcohol spectrum disorders (FASD) can be optimized when individual and family needs are identified early and met with family-centered early intervention (EI) services. However, little is known about access to and quality of EI services with this high-needs population.

METHOD

Twenty-five biological or adoptive parents of children with or at high risk for FASD, living in the greater area of Seattle, Washington participated in this qualitative study. Three focus groups were conducted using a semi-structured interview guide. Participants described their experience with EI, as well as other supports and challenges faced in their child's first three years of life. Interviews were audio recorded, transcribed verbatim and coded using phenomenological methods. Themes that were consistent across participant groups emerged from the data, as well as themes that showed differences among participant experiences.

RESULTS

Common EI supports and needs between biological and adoptive parent groups were identified. In addition, perspectives and needs unique to each parent group were revealed. Themes were identified and organized into three categories: (1) child needs; (2) parent needs and priorities; and (3) EI capacity. When parents talked about their child's cognitive, physical, communication or adaptive development, they all discussed how EI was meeting those needs. In contrast, when parents expressed concern for their child's social-emotional development, a description of how EI was supporting these needs was missing from the conversation. Parents appreciated when EI providers were truthful, provided anticipatory guidance, and connected them with supports for their own social-emotional well-being. Yet there were unmet needs for respite care, and parents expressed that support for basic needs related to child or family survival was not consistently recognized as a top priority for families. This high-risk group of young children and their parents also encountered a multitude of transitions in their child's early years and later. Parents wanted more support navigating these transitions as they entered or moved through different systems of care.

CONCLUSIONS

Parents appreciated and endorsed the importance of EI with its provision of individualized, family-centered supports and resources. Examination of the gaps and unmet needs that are common and distinct underscore the importance of an FASD-informed approach to EI. Study findings provide insight into areas for which EI enhancements could be developed in order to tailor supports for the complex needs of this diverse population of children and parents.

Contextual influences on the perception of pregnant women who use drugs: Information about women's childhood trauma history reduces punitive attitudes

Punitive attitudes and consequences (e.g., incarceration) for prenatal illicit drug use persist in the United States despite evidence that these policies are ineffective and even harmful to women and children. For instance, the threat of these consequences can deter women from seeking healthcare, prenatal care, and drug treatment. Punitive responses may persist due to pejorative public perceptions of pregnant women who use illicit drugs. Although there is evidence that contextual information about prenatal drug use (e.g., drug type) can change such perceptions, other contextual influences are unknown. This experimental study tested whether receiving contextual information about a pregnant woman who uses drugs (specifically, her childhood trauma history) reduces punitive and increases supportive attitudes toward the woman. In a vignette-based 2(pregnancy status: pregnant/not pregnant) x 2(history of childhood trauma: interpersonal/non-interpersonal) between-subjects design, young adult university participants (N = 461) were randomly assigned to read a vignette about a woman who uses methamphetamine. Punitive attitudes were significantly reduced by information that the pregnant woman had a history of childhood trauma, especially interpersonal (versus non-interpersonal) trauma (η_p² = .115). Supportive attitudes were not impacted (η_p² = .005). Information about the pregnant woman's trauma history predicted less agreement with incarcerating her, only indirectly, through less punitive attitudes (R² = .21). Reductions in punitive attitudes were on the order of 1.5-2 points on 5-point self-report scales and controlled for participant gender and political conservatism. Results have practical implications for interdisciplinary work aimed at unlocking greater support for policies that help pregnant women make safe, informed decisions with dignity and access to healthcare.

Using a Developmental-Relational Approach to Understand the Impact of Interpersonal Violence in Women Who Struggle with Substance Use

Substance use among women is a major public health concern. This review article takes a developmental-relational approach to examine processes through which early relational trauma and violence in relationships may lead to substance use. We examine how early exposure to violence in relationships can impact neurological development, specifically through interference with physiological mechanisms (e.g., the hypothalamic-pituitary-adrenal axis), brain structure and functioning (e.g., the hippocampus and prefrontal cortex), and neuropsychological development (e.g., executive functioning and emotion regulation) across the lifespan. Further, we discuss the impact of exposure to violence on the development of relational capacity, including attachment, internal working models, and subsequent interpersonal relationships across the lifespan, and how these developmental pathways can lead to continued problematic substance use in women.

Addressing the Impact of Interpersonal Violence in Women Who Struggle with Substance Use Through Developmental-Relational Strategies in a Community Program

From a developmental-relational framework, substance use in women can be understood as relating to early experiences of violence in relationships and across development. This article uses a developmental-relational approach to outline specific strategies that can be used by service providers and to guide interventions for women with substance use issues. By reviewing research and clinical work with women attending a community-based prevention and early intervention program, we describe how specific components of programming can target the developmental and intergenerational pathway between experiences of violence in relationships and substance use. We include the voices of women who attended the program to support the strategies discussed. Specifically, these strategies address the impact of interpersonal violence on substance use by promoting the process of repair and reintegration for women whose neurological development, sense of self, and capacity to form relationships have been significantly impacted by experiences of violence in relationships.

Multi-Service Programs for Pregnant and Parenting Women with Substance Use Concerns: Women's Perspectives on Why They Seek Help and Their Significant Changes

Within Canada, several specialized multi-service prevention programs work with highly vulnerable pregnant and early parenting women with substance use issues. Experiences of trauma, mental health, poverty, and other factors associated with the social determinants of health complete the picture. Program evaluations have demonstrated their value, but less has been said as to women’s reasons for choosing to seek help from these programs, what they were hoping to gain, or what difference they believe has occurred as a result. The Co-creating Evidence project is a multi-year (2017–2020) national evaluation of holistic programs serving women at high risk of having an infant with prenatal alcohol or substance exposure. The evaluation uses a mixed methods design involving quarterly program output and “snapshot” client data, as well as in-person, semi-structured interviews and questionnaires with clients, program staff, and program partners. This article presents findings from interviews with women regarding why they sought help, how they used the services, and what they perceived to be the most significant change in their lives as a result. Obtaining help with substance use was the top theme for what women hoped to get from their participation in their program; however, women’s reasons were often intertwined. Additional motivations included wanting information, support or assistance with: child welfare; pregnancy; housing; getting connected to health care or prenatal care; and opportunities for peer support. With respect to the most significant life change, themes included: reduced substance use; improved housing; stronger mother–child connection; and improved wellness and social connections. Findings demonstrated that vulnerable, marginalized pregnant and parenting women who are using substances will seek help when health and social care services are configured in such a way as to take into consideration and address their unique roles, responsibilities, and realities.

National Evaluation of Canadian Multi-Service FASD Prevention Programs: Interim Findings from the Co-Creating Evidence Study

Since the 1990s, a number of multi-service prevention programs working with women who have substance use, mental health, or trauma and/or related social determinants of health issues have emerged in Canada. These programs use harm reduction approaches and provide outreach and “one-stop” health and social services on-site or through a network of services. While some of these programs have been evaluated, others have not, or their evaluations have not been published. This article presents interim qualitative findings of the Co-Creating Evidence project, a multi-year (2017–2020) national evaluation of holistic programs serving women at high risk of having an infant with prenatal alcohol exposure. The evaluation utilizes a mixed-methods design involving semi-structured interviews, questionnaires, focus groups, and client intake/outcome “snapshot” data. Findings demonstrated that the programs are reaching vulnerable pregnant/parenting women who face a host of complex circumstances including substance use, violence, child welfare involvement, and inadequate housing; moreover, it is typically the intersection of these issues that prompts women to engage with programs. Aligning with these results, key themes in what clients liked best about their program were: staff and their non-judgmental approach; peer support and sense of community; and having multiple services in one location, including help with mandated child protection.