Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme

Maternal Substance Use and Early-Life Adversity: Inducing Drug Dependence in Offspring, Interactions, Mechanisms, and Treatments

The likelihood of substance dependency in offspring is increased in cases when there is a family history of drug or alcohol use. Mothering is limited by maternal addiction because of the separation. Maternal separation (MS) leads to the development of behavioural and neuropsychiatric issues in the future. Despite the importance of this issue, empirical investigations of the influences of maternal substance use and separation on substance use problems in offspring are limited, and studies that consider both effects are rare. This study aims to review a few studies on the mechanisms, treatments, genetics, epigenetics, molecular and psychological alterations, and neuroanatomical regions involved in the dependence of offspring who underwent maternal addiction and separation. The PubMed database was used. A total of 95 articles were found, including the most related ones in the review. The brain's lateral paragigantocellularis (LPGi), nucleus accumbens (NAc), caudate-putamen (CPu), prefrontal cortex (PFC), and hippocampus, can be affected by MS. Dopamine receptor subtype genes, alcohol biomarker minor allele, and preproenkephalin mRNA may be affected by alcohol or substance use disorders. After early-life adversity, histone acetylation in the hippocampus may be linked to brain-derived neurotrophic factor (BDNF) gene epigenetics and glucocorticoid receptors (GRs). The adverse early-life experiences differ in offspring›s genders and rewire the brain›s dopamine and endocannabinoid circuits, making offspring more susceptible to dependence. Related psychological factors rooted in early-life stress (ELS) and parental substance use disorder (SUD). Treatments include antidepressants, histone deacetylase inhibitors, lamotrigine, ketamine, choline, modafinil, methadone, dopamine, cannabinoid 1 receptor agonists/antagonists, vitamins, oxytocin, tetrahydrocannabinol, SR141716A, and dronabinol. Finally, the study emphasizes the need for multifaceted strategies to prevent these outcomes.

The Secondary Harms of Parental Substance Use on Children's Educational Outcomes: A Review

Parental substance use, that is alcohol and illicit drugs, can have a deleterious impact on child health and wellbeing. An area that can be affected by parental substance use is the educational outcomes of children. Current reviews of the literature in the field of parental substance use and children's educational outcomes have only identified a small number of studies, and most focus on children's educational attainment. To grasp the available literature, the method from Arksey and O'Malley (2005) was used to identify literature. Studies were included if they were empirical, after 1950, and focused on children's school or educational outcomes. From this, 51 empirical studies were identified which examined the relationship between parental alcohol and illicit drug use on children's educational outcomes. Five main themes emerged which included attainment, behavior and adjustment, attendance, school enjoyment and satisfaction, academic self-concept, along with other miscellaneous outcomes. This paper highlights the main findings of the studies, the gaps in the current literature, and the challenges presented. Recommendations are made for further research and interventions in the areas of parental substance use and child educational outcomes specifically, but also for broader areas of adversity and child wellbeing.

The Family Check-Up Online: A Telehealth Model for Delivery of Parenting Skills to High-Risk Families With Opioid Use Histories

Growing opioid misuse in the United States has resulted in more children living with an adult with an opioid use history. Although an abundance of research has demonstrated a link between opioid misuse and negative parenting behaviors, few intervention efforts have been made to target this underserved population. The Family Check-Up (FCU) has been tested in more than 25 years of research, across multiple settings, and is an evidence-based program for reducing risk behavior, enhancing parenting skills, and preventing the onset of substance use. It is designed to motivate parents to engage in positive parenting practices and to change problematic parenting and has been tested across a variety of ages including early childhood and adolescence. It is highlighted in NIDA’s Principles of Substance Use Prevention for Early Childhood: A research-based guide as one of only three effective selective prevention programs for substance abuse among families with young children. Recently, we developed an online version of the FCU that has now been adapted for early childhood and families with opioid use histories. The online platform and telehealth model allow for wide-scale dissemination, ease of training with community providers, and increased public health reach for families in remote, rural areas. This is particularly important when targeting families with opioid misuse and addiction because there are high rates of addiction in remote areas, yet few services available. In this article, we describe the FCU Online and review new content in the model that targets a population of young adult parents with substance abuse histories, including opioid use. New modules include content focused on harm reduction for this high-risk population of parents, such as safety in the home, substance use while parenting, and managing conflict with partners and friends.

Preschool Language Development of Children Born to Women with an Opioid Use Disorder

Increasing evidence suggests that prenatal exposure to opioids may affect brain development, but limited data exist on the effects of opioid-exposure on preschool language development. Our study aimed to characterize the nature and prevalence of language problems in children prenatally exposed to opioids, and the factors that support or hinder language acquisition. A sample of 100 children born to pregnant women in methadone maintenance treatment and 110 randomly identified non-exposed children were studied from birth to age 4.5 years. At 4.5 years, 89 opioid-exposed and 103 non-exposed children completed the preschool version of the Clinical Evaluation of Language Fundamentals (CELF-P) as part of a comprehensive neurodevelopmental assessment. Children prenatally exposed to opioids had poorer receptive and expressive language outcomes at age 4.5 years compared to non-opioid exposed children. After adjustment for child sex, maternal education, other pregnancy substance use, maternal pregnancy nutrition and prenatal depression, opioid exposure remained a significant independent predictor of children’s total CELF-P language score. Examination of a range of potential intervening factors showed that a composite measure of the quality of parenting and home environment at age 18 months and early childhood education participation at 4.5 years were important positive mediators.

Mothers experiences of the Parenting Under Pressure Program (PuP) in a Residential Therapeutic Community: A qualitative study

Several studies suggest parental substance use, while not always the case, exposes children to a higher risk of physical, psychological, behavioral and emotional problems. Identifying interventions that best support the parent and child needs is imperative. The PuP programme aims to improve family functioning and child outcomes by supporting parents who are or have been drug or alcohol dependent. PuP combines psychological principles relating to parenting, child behavior and parental emotion regulation within a case-management model. The current study was the first evaluation of the PuP program in a residential setting globally. Twenty-three women took part in pre and post-program qualitative interviews. Guilt was a dominant theme across interviews. The principal expectation of participants was to improve their relationships and access to their children. The benefits of the PuP program to the women and their children, as reported by participants, were immediate and direct. As the women progressed through the program, they were visibly building belief in their abilities to parent.

Correlates of Expressed Emotion Among Family Members of Individuals Who Sought Treatment for Opioid Use

Expressed emotion has been robustly associated with negative mental health outcomes. Understanding correlates of expressed emotion by family members of individuals with opioid use disorder is important, as this group faces high levels of stress and can play an important role in their loved ones' treatment. Thus, immediate family members of individuals who sought treatment for opioid problems (N = 195) completed a web-based survey that included measures of expressed emotion, self-stigma, social support, and demographic characteristics. Multiple linear regression analyses were conducted to examine correlates of two types of expressed emotion-criticism and emotional overinvolvement. Results indicated that higher self-stigma and lower social support were significantly associated with higher emotional overinvolvement. Higher self-stigma and having experienced debt related to a family member's opioid use were associated with higher criticism. Thus, self-stigma and financial burden may exacerbate likelihood of expressed emotion, whereas social support may buffer against expressed emotion.

Informing children of their parent's illness: A systematic review of intervention programs with child outcomes in all health care settings globally from inception to 2019

Introduction

Children are impacted when parents are ill. This systematic review gives an overview of the current state of research and extracts what children and parents found helpful in the interventions aimed at informing children of their parent’s illness.

Methods

This review was registered with PROSPERO and conducted in accordance with PRISMA guidelines. Five health and social science databases were searched from inception to November 2019 to identify original, peer-reviewed articles in English describing effective interventions. The authors selected and reviewed the studies independently, and any inconsistencies were resolved by discussion in face-to-face meetings and emails. A descriptive synthesis of evidence-based concepts from quantitative and qualitative studies was conducted.

Results

A total of 13 892 titles and 144 full-text articles were reviewed with 32 selected for final inclusion, 21 quantitative, 11 qualitative and no mixed-method studies published from 1993 to November 2019. Most of the research was conducted in mental health, including substance abuse (n = 22), but also in cancer care (n = 6) and HIV care (n = 4). Most studies using quantitative method showed a small to moderately positive statistically significant intervention effect on the child’s level of internalized symptoms. Content analysis of the results of studies employing qualitative methodology resulted in four concepts important to both children and parents in interventions (increased knowledge, more open communication, new coping strategies and changed feelings) and three additional concepts important to parents (observed changes in their children’s behavior, the parent’s increased understanding of their own child and the relief of respite).

Conclusions

In the literature there is evidence of mild to moderate positive effects on the child’s level of internalized symptoms as well as concepts important to children and parent’s worth noting when trying to bridge the still existing knowledge gaps. In further efforts the challenges of implementation as well as adaptation to differing clinical and personal situations appear key to address.

After NAS

Mothers have used opioids for thousands of years but neonatal abstinence syndrome (NAS) or rather, survivors of NAS, is a modern phenomenon. Unrecognized and/or untreated opioid withdrawal was almost always fatal but with greater awareness and standardization of treatment, NAS is now an uncommon direct cause of infant death. However, opioids are now increasingly accessible and potent and the outcomes of children after the neonatal period are of great concern, especially when coupled with multiple other social and health risks. Complex individual, environmental and genetic factors need to be considered when assessing outcomes or future research for babies with NAS. Any intervention or research efforts must address these multifactorial complexities. This review will discuss pertinent post neonatal outcomes, including mortality, physical and mental health and social functioning of children with a history of NAS.

Retrospective study found that outpatient care for infants exposed to drugs during pregnancy was sustainable and safe

AIM

We determined the safety, feasibility and sustainability of an outpatient model of care for infants exposed to intra-uterine drugs.

METHODS

This was a retrospective chart review of 774 drug-exposed infants born between 1998 and 2016 at the Royal Hospital for Women, Sydney, Australia.

RESULTS

Most (86%) of the mothers used multiple drugs, including opioids (58%). More than three-quarters (78%) of the infants were born full term at a mean gestation of 38 weeks and hospitalised for a median of seven days. This rose to 14 days if they were medicated for neonatal abstinence syndrome (NAS). Most of the NAS patients (83%) were discharged on medication, namely morphine, and the median duration of NAS treatment was 76 (interquartile range 35-120). Three medication errors occurred: two extra doses of phenobarbitone and one infant weaned off morphine faster than prescribed. No infants were rehospitalised for NAS. Four died from sudden infant death syndrome at 2.2-5.8 months after discharge and one drowned at 15 months. None were medicated at the time of death.

CONCLUSION

Outpatient care for drug-exposed infants was sustainable and had low complication rates, even for those with NAS. The optimum duration of follow-up and impact on hospital costs should be examined.

A randomized controlled trial and economic evaluation of the Parents Under Pressure program for parents in substance abuse treatment

BACKGROUND

There is growing interest in the provision of parenting support to substance misusing parents.

METHODS

This pragmatic, multi-center randomized controlled trial compared an intensive one-to-one parenting program (Parents under Pressure, PuP) with Treatment as Usual (TAU) in the UK. Parents were engaged in community-based substance misuse services and were primary caregivers of children less than 2.5 years of age. The primary outcome was child abuse potential, and secondary outcomes included measures of parental emotional regulation assessed at baseline, 6 and 12-months. A prospective economic evaluation was also conducted.

RESULTS

Of 127 eligible parents, 115 met the inclusion criteria, and subsequently parents were randomly assigned to receive PuP (n = 48) or TAU (n = 52). Child abuse potential was significantly improved in those receiving the PuP program while those in TAU showed a deterioration across time in both intent-to-treat (p < 0.03) and per-protocol analyses (p < 0.01). There was also significant reliable change (recovery/improvement) in 30.6% of the PuP group compared with 10.3% of the TAU group (p < 0.02), and deterioration in 3% compared with 18% (p < 0.02). The probability that the program is cost-effective was approximately 51.8% if decision-makers are willing to pay £1000 for a unit improvement in the primary outcome, increasing to 98.0% at a £20,000 cost-effectiveness threshold for this measure.

CONCLUSIONS

Up to one-third of substance dependent parents of children under 3-years of age can be supported to improve their parenting, using a modular, one-to-one parenting program. Further research is needed.

Adult consequences of prenatal drug exposure

Maternal drug use is not new but over the last few decades, the number of mothers using drugs of addiction has escalated to epidemic levels. These drugs are both legal (e.g. prescription medication) and illegal (e.g. heroin) and all will cross the placental barrier into the developing infant. The most immediate and obvious consequence of intra-uterine drug exposure is newborn withdrawal or the Neonatal Abstinence Syndrome (NAS) which is now, with prompt recognition and treatment, an uncommon cause of neonatal death. Thousands (if not millions) of adults most likely would have had a history of passive drug exposure during gestation and the outcomes of these people are unknown. Most are physically healthy and do not need extra medical attention but the effects of prenatal drug exposure may be subtle and extensive. Drug-use disorders are accompanied by a myriad of other adverse problems, including poverty, mental and physical health problems and inadequate parenting ability that may compound the negative effects of drugs. Emerging data suggest that vulnerability to health and neurocognitive issues are pervasive and long-lasting as are lifestyle issues. This review will address current evidence in this area and highlight the knowledge gaps that must be addressed in order to optimise the outcomes for this vulnerable and marginalised but rapidly expanding population of adults.

Opioid substitution treatment and heroin dependent adolescents: reductions in heroin use and treatment retention over twelve months

BACKGROUND

Opioid dependence is a major health concern across the world and does also occur in adolescents. While opioid substitution treatment (OST) has been thoroughly evaluated in adult populations, very few studies have examined its use in adolescents. There are concerns that OST is underutilised in adolescents with heroin dependence. We sought to measure changes in drug use among adolescents receiving OST and also to examine treatment attrition during the first 12 months of this treatment.

METHODS

We included all heroin dependent patients aged under 18.5 years commencing OST at one outpatient multidisciplinary adolescent addiction treatment service in Dublin, Ireland. Psycho-social needs were also addressed during treatment. Drug use was monitored by twice weekly urine drugs screens (UDS). Change in the proportion of UDS negative for heroin was examined using the Wilcoxon signed rank test. Attrition was explored via a Cox Regression multivariate analysis.

RESULTS

OST was commenced by 120 patients (51% female and mean age 17.3 years). Among the 39 patients who persisted with OST until month 12, heroin abstinence was 21% (95% confidence interval [CI] = 9-36%) at month three and it was 46% (95% CI = 30-63%) at month 12. Heroin use declined significantly from baseline to month three (p < 0.001) and from month three to month 12 (p = 0.01). Use of other drugs did not change significantly. People using cocaine during month 12 were more likely to be also using heroin (p = 0.02). Unplanned exit occurred in 25% patients by 120 days. The independent predictors of attrition were having children, single parent family of origin, not being in an intimate relationship with another heroin user and evidence of cocaine use just before treatment entry.

CONCLUSIONS

We found that heroin dependent adolescent patients achieved significant reductions in heroin use within three months of starting OST and this improved further after a year of treatment, about half being heroin abstinent at that stage. Patient drop out from treatment remains a challenge, as it is in adults. Cocaine use before and during treatment may be a negative prognostic factor.

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

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

A naturalistic longitudinal analysis of post-detoxification outcomes in opioid-dependent patients

INTRODUCTION AND AIMS

To provide an assessment of outcomes in a cohort of opioid-dependent patients post-detoxification.

DESIGN AND METHODS

This study employed an observational longitudinal cohort design. Patients who completed detoxification in the three major Drug Dependency Units in Ireland during a 14-month period were included in the study (n = 143). Patients opting for one of the three pathways post-detoxification (inpatient aftercare, outpatient aftercare or no formal aftercare) were assessed in the final week of detoxification and followed up after 3, 6 and 9 months. The primary outcome was abstinence following detoxification.

RESULTS

A Cox (adjusted) model indicated participants who opted for outpatient aftercare treatment lapsed/relapsed at a rate of 52% higher than the inpatient aftercare group (hazard ratio = 1.52, 95% confidence interval 0.75-3.08, P = 0.24). Moreover, time to lapse/relapse was considerably shorter for the no formal aftercare group (hazard ratio = 7.68, 95% confidence interval 4.30-13.73, P = 5.75 × 10^-12 ). Abstinence rates for outpatient aftercare and inpatient aftercare are about equal after 9 months.

DISCUSSION AND CONCLUSION

Patients who opt for aftercare post-detoxification have significantly better outcomes at follow up when compared to no formal aftercare. In addition, patients' intention to attend aftercare affected their outcomes regardless of eventual treatment path.

The Impact of Social Support and Attachment Style on Quality of Life and Readiness to Change in a Sample of Individuals Receiving Medication-Assisted Treatment for Opioid Dependence

BACKGROUND

A basic principle within the addictions treatment field is that social support is a vital ingredient in the recovery process. This study examines the nature of social support in a sample of opioid-dependent men and women who are currently being treated in a medication-assisted treatment program (methadone). This research examines the types of social support behaviors that the opioid-dependent individuals consider helpful and explores whether attachment style (i.e., secure, ambivalent, or anxious attachment) was a determining factor in whether social support was perceived as helpful. The dependent variables included readiness to change addictive behaviors and abstinence from other mood-altering drugs.

METHODS

Participants (N = 159) completed a demographic questionnaire, the Significant Others Scale, the Experiences in Close Relationships Scale, the Multidimensional Scale of Perceived Social Support Assessment, the Readiness to Change Scale, and an Attachment Style Questionnaire. The demographic questionnaire included subjective ratings of self-improvement.

RESULTS

Social support predicted perceived improvement in all of the areas examined (e.g., health, family/social relationships) and abstinence; however, attachment style did not predict improvement or with readiness to change.

CONCLUSIONS

Social support is an important factor in one's recovery from substance use disorders. Yet attachment style (i.e., anxious, avoidant, or secure) did not predict abstinence or overall improvement in functioning.

Mother-child interaction and cognitive development in children prenatally exposed to methadone or buprenorphine

OBJECTIVE

To assess the influence of mother-child interaction on children's cognitive development in a group of children prenatally exposed to methadone or buprenorphine.

STUDY DESIGN

The study is part of a prospective longitudinal project investigating the development of children born to women in opioid maintenance therapy (OMT). The sample includes 67 children born between 2005 and 2007, 35 of which prenatally exposed to either methadone or buprenorphine and 32 non-exposed comparison children.

RESULTS

Both groups scored within the normal range of development. However, the OMT group scored significantly lower on measures of cognitive development and mother-child interaction compared to the comparison group. Cognitive development was found to be affected by both group status, F(1,54)=5.65, p=0.02, η(2)=0.10 and mother-child interaction F(1,54)=5.26, p=0.03, η(2)=0.09. Behavioral inhibition (statue), sensorimotor function (imitating hand positions), and short-term memory (sentences) was influenced by group status while narrative memory and vocabulary were found to be more influenced by mother-child interaction.

CONCLUSIONS

Different risk factors may influence different cognitive functions in children of women in OMT. Specifically, language-related cognitive skills may be more related to mother-child interaction while performance in higher cognitive functions requiring precise control over sensorimotor responses may be more sensitive to other factors such as prenatal OMT exposure, genetics, and/or prenatal exposure to other substances.

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

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

Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior

Evidence-based interventions are often unavailable in everyday clinical settings. This may partly reflect practitioners' assumptions that research evidence does not reflect "real-world" conditions. To examine this further, we systematically assessed the clinical effectiveness of parent management training (PMT) for the treatment of child disruptive behavior across different real-world practice contexts. We identified 28 relevant randomized controlled trials from a systematic search of electronic bibliographic databases and conducted a meta-analysis of child outcomes across trials. Planned subgroup analyses involved comparisons between studies grouped according to individual real-world practice criteria and total real-world practice criteria scores, reflecting the extent to which PMT was delivered by non-specialist therapists, to a clinic-referred population, in a routine setting, and as part of a routine service. Meta-analysis revealed a significant overall advantage for PMT compared with waitlist control conditions. Subgroup analyses did not demonstrate significant differences in effect size estimates according to the total number of real-world practice criteria met by studies. Moreover, no consistent relationships were found between specific practice criteria and effect size estimates. In conclusion, PMT appears to be an effective treatment for children with disruptive behavior problems. There was no clear evidence that conducting PMT in real-world practice contexts is a deterrent to achieving effective child behavior outcomes, although relative advantage to "usual care" was not directly examined and the power of the analysis was limited as a result of significant heterogeneity. More research is needed to investigate whether this finding is generalizable to other psychological interventions. Suggestions are also made for developing more differentiated criteria to assist with evaluating the specific applicability of research evidence to different care providers.

An evaluation of the parents under pressure programme: a study protocol for an RCT into its clinical and cost effectiveness

BACKGROUND

Many babies in the UK are born to drug-dependent parents, and dependence on psychoactive drugs during the postnatal period is associated with high rates of child maltreatment, with around a quarter of these children being subject to a child protection plan. Parents who are dependent on psychoactive drugs are at risk of a wide range of parenting problems, and studies have found reduced sensitivity and responsiveness to both the infant's physical and emotional needs. The poor outcomes that are associated with such drug dependency appear to be linked to the multiple difficulties experienced by such parents.An increase in understanding about the crucial importance of early relationships for infant well-being has led to a focus on the development and delivery of services that are aimed at supporting parenting and parent-infant interactions. The Parents under Pressure (PuP) programme is aimed at supporting parents who are dependent on psychoactive drugs or alcohol by providing them with methods of managing their emotional regulation, and of supporting their new baby's development. An evaluation of the PuP programme in Australia with parents on methadone maintenance of children aged 3 to 8 years found significant reductions in child abuse potential, rigid parenting attitudes and child behaviour problems.

METHODS/DESIGN

The study comprises a multicentre randomised controlled trial using a mixed-methods approach to data collection and analysis in order to identify which families are most able to benefit from this intervention.The study is being conducted in six family centres across the UK, and targets primary caregivers of children less than 2.5 years of age who are substance dependent. Consenting participants are randomly allocated to either the 20-week PuP programme or to standard care.The primary outcome is child abuse potential, and secondary outcomes include substance use, parental mental health and emotional regulation, parenting stress, and infant/toddler socio-emotional adjustment scale.

DISCUSSION

This is one the first UK studies to examine the effectiveness of a programme targeting the parenting of substance-dependent parents of infants and toddlers, in terms of its effectiveness in improving the parent-infant relationship and reducing the potential for child abuse.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Register: ISRCTN47282925.

Supporting mothers' engagement in a community-based methadone treatment program

Unmanaged maternal opioid addiction poses health and social risks to both mothers and children in their care. Methadone maintenance treatment (MMT) is a targeted public health service to which nurses and other allied health professionals may refer these high risk families for support. Mothers participating in MMT to manage their addiction and their service providers were interviewed to identify resources to maximize mothers' engagement in treatment and enhance mothers' parenting capacity. Twelve mothers and six service providers were recruited from an outpatient Atlantic Canadian methadone treatment program. Two major barriers to engagement in MMT were identified by both mothers and service providers including (1) the lack of available and consistent childcare while mothers attended outpatient programs and (2) challenges with transportation to the treatment facility. All participants noted the potential benefits of adding supportive resources for the children of mothers involved in MMT and for mothers to learn how to communicate more effectively with their children and rebuild damaged mother-child relationships. The public health benefits of integrating parent-child ancillary supports into MMT for mothers are discussed.

The contribution of mindfulness-based therapies for children and families and proposed conceptual integration

BACKGROUND

  Mindfulness is the development of a nonjudgmental accepting awareness of moment-by-moment experience. Intentionally attending to one's ongoing stream of sensations, thoughts, and emotions as they arise has a number of benefits, including the ability to react with greater flexibility to events and sustain attention. Thus the teaching of mindfulness-based skills to children and their carers is a potential means of improving family relationships and helping children achieve more positive developmental outcomes through increased ability to sustain attention and manage emotions. We provide a review of recent studies evaluating mindfulness-based interventions targeting children, adolescents, and families in educational and clinical settings.

METHOD

  Searches were conducted of several databases (including Medline, PsychINFO and Cochrane Reviews) to identify studies that have evaluated mindfulness-based interventions targeting children, adolescents or families published since 2009.

RESULTS

  Twenty-four studies were identified. We conclude that mindfulness-based interventions are an important addition to the repertoire of existing therapeutic techniques. However, large-scale, methodologically rigorous studies are lacking. The interventions used in treatment evaluations vary in both content and dose, the outcomes targeted have varied, and no studies have employed methodology to investigate mechanisms of change.

CONCLUSIONS

  There is increasing evidence that mindfulness-based therapeutic techniques can have a positive impact on a range of outcome variables. A greater understanding of the mechanisms of change is an important future direction of research. We argue that locating mindfulness-based therapies targeting children and families within the broader child and family field has greater promise in improving child and family functioning than viewing mindful parenting as an independent endeavor.

Opioid dependency in pregnancy and length of stay for neonatal abstinence syndrome

OBJECTIVE

To examine opioid replacement therapy in pregnancy and effect on neonatal outcomes, including length of hospital stay for neonatal abstinence syndrome.

DESIGN

Retrospective descriptive study.

SETTING

Labor and delivery unit and neonatal intensive care unit (NICU), Eastern Maine Medical Center, Bangor, Maine.

PARTICIPANTS

One hundred fifty-two opioid-dependent pregnant women on methadone maintenance therapy (MMT) (n = 136) or buprenorphine maintenance therapy (BMT) (n = 16) during pregnancy and their neonates. The neonates were born between January 1, 2005 and December 31, 2007.

METHODS

A review of the electronic medical record (EMR) was conducted of all opioid-dependent women who were maintained on MMT or BMT at the time of admission for labor and delivery and their neonates.

RESULTS

Maternal methadone dose and concomitant in-utero exposure to benzodiazepines prolonged the length of hospital stay for neonates. Length of stay was shorter in breastfed neonates than formula-fed neonates or neonates who received formula and breast milk. Neonates with prenatal exposure to MMT spent more days in the hospital (21 vs. 14 days) for treatment of neonatal abstinence syndrome (NAS) than infants with prenatal exposure to BMT.

CONCLUSION

These findings are consistent with previous research on the simultaneous use of methadone and benzodiazepines during pregnancy and provide further direction for the treatment of opioid dependency during pregnancy. Harm reduction strategies for opioid-dependent pregnant women in substance abuse treatment with MMT may one day include guidance on daily treatment doses and recommendations to avoid the concomitant use of benzodiazepines to lessen NAS. Breastfeeding should be recommended to shorten length of stay. Understanding perinatal and neonatal outcomes of pregnant women on methadone or buprenorphine will help to identify optimal treatment for opioid dependency in pregnancy.

Getting the mix right: family, community and social policy interventions to improve outcomes for young people at risk of substance misuse

Societal responses to the existence of substance misuse fluctuate between harm minimisation and prohibition. Both approaches are predominantly downstream reactions to substance misuse that focus on the supply of harmful substances and the containment of misuse through treatment, rehabilitation or punishment. Until recently, little attention has been paid to the upstream individual, family, relationship, community or societal antecedents of substance misuse (which often overlap with those for other adverse life outcomes, such as unemployment, antisocial personality disorder and mental health problems) that have operated during earlier life. A growing body of evidence highlights the overlapping biological and experiential antecedents for substance abuse and other poor outcomes as well as the trajectory-changing protective factors that can prevent risks being translated into destiny. Risk minimisation and protection enhancement embedded in family and social systems are the essential building blocks of a set of early intervention strategies that begin antenatally and continue through the developing years of childhood, adolescence and young adult life, that have been shown to be effective in improving many outcomes in development, health and well-being. Much remains to be done to enable the promise of effective universal and targeted early intervention to be translated into policies, programs and practices that could be life-changing for citizens bogged in the mire of substance misuse and their children. Realistic, timely investment, influenced by the best scientific evidence indicating what works, for whom, under what circumstances, an increased degree of collaboration within and between governments and their agencies to enable "whole of government" responses in partnership with community-based initiatives are essential along with investments in multidisciplinary program evaluation research that will enable evidence-informed policy decisions to be tailored to the needs of individual countries.

Abstinence Social Support: The Impact of Children in Oxford House

The present study compared the characteristics of individuals living with (42 men, 52 women) and without children (561 men, 241 women) residing in an communal-iving recovery program called Oxford Houses.. Results indicated that men living with children and women living without children had more general social support, compared to men living without children and women living with children. Additionally, women and residents of adult-only houses reported having more drug users in their social networks. However, men and women living with and without children reported similar levels of social support for abstinence. It is suggested that that men in recovery who take care of their children are in situations more advantageous to sustained recovery and have more resources compared to recovering women with children. Women in substance abuse recovery and taking care of children may require additional resources and assistance compared to men.

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

AIMS

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

DESIGN

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

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

Reducing potential for child abuse among methadone-maintained parents: results from a randomized controlled trial

High rates of child abuse and neglect occur in many families in which either or both parents abuse illicit drugs. This study reports on the results of a randomized controlled trial with families having a parent on methadone maintenance (N = 64), in which an intensive, home-based intervention, the Parents Under Pressure (PUP) program, was compared to standard care. A second brief intervention control group of families received a two-session parenting education intervention. The PUP intervention draws from the ecological model of child development by targeting multiple domains of family functioning including the psychological functioning of individuals in the family, parent-child relationships, and social contextual factors. Mindfulness skills were included to address parental affect regulation, a significant problem for this group of parents. At 3- and 6-month follow-up, PUP families showed significant reductions in problems across multiple domains of family functioning, including a reduction in child abuse potential, rigid parenting attitudes, and child behavior problems. Families in the brief intervention group showed a modest reduction in child abuse potential but no other changes in family function. There were no improvements found in the standard care group and some significant worsening was observed. Results are discussed in terms of their implications for improved treatment.

Psychiatric problems of children exposed to opiates in utero - a descriptive study

OBJECTIVES

To describe the psychosocial and clinical characteristics of children referred to a community-based child and adolescent mental health service, whose mothers reported that they took opiates during the pregnancy.

METHODS

In a retrospective study, the case notes of all children whose mothers reported that they had been exposed to opiates in utero, and who were referred to the Department of Child and Family Psychiatry, Mater Hospital, between 2001-2003, were identified by maternal reports. Information was obtained on age, gender, referral source, socio-economic group, family type, number of siblings, involvement of community care services, nature of presenting problems, diagnosis, interventions offered, and treatment difficulties. Information was recorded anonymously.

RESULTS

15 children were identified, of whom nine were male. Most were found to be living with their mother alone or with their mother and a partner, and to be socially and financially disadvantaged. Their presenting complaints usually involved combinations of aggressive, hyperactive, and oppositional behaviour. Diagnoses included ADHD, a speech and language disorder, and an axis II disorder. Interventions were frequently unsuccessful because of parents' difficulties with attending appointments, and because of instability in the families' living arrangements.

CONCLUSIONS

These children, due to a complex interplay of biological and psychosocial adversity, are at serious risk of ongoing psychiatric disorders in childhood and adolescence, and for adverse outcomes in adult life. A prospective cohort study of all children born to opiatedependent mothers is necessary to quantify the level of risk and identify resilience factors.

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

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