Mother-infant interaction: effects of a home intervention and ongoing maternal drug use

Early emotional caregiving environment and associations with memory performance and hippocampal volume in adolescents with prenatal drug exposure

Early adversities, including prenatal drug exposure (PDE) and a negative postnatal emotional caregiving environment, impact children's long-term development. The protracted developmental course of memory and its underlying neural systems offer a valuable framework for understanding the longitudinal associations of pre- and postnatal factors on children with PDE. This study longitudinally examines memory and hippocampal development in 69 parent-child dyads to investigate how the early caregiving emotional environment affects children with PDE's neural and cognitive systems. Measures of physical health, drug exposure, caregiver stress, depression, and distress were collected between 0 and 24 months At age 14 years, adolescents completed multiple measures of episodic memory, and at ages 14 and 18 years, adolescents underwent magnetic resonance imaging (MRI) scans. Latent constructs of episodic memory and the caregiving environment were created using Confirmatory Factor Analysis. Multiple regressions revealed a negative emotional caregiving environment during infancy was associated with poor memory performance and smaller left hippocampal volumes at 14 years. Better memory performance at 14 years predicted larger right hippocampal volume at 18 years. At 18 years, the association between the emotional caregiving environment and hippocampal volume was moderated by sex, such that a negative emotional caregiving environment was associated with larger left hippocampal volumes in males but not females. Findings suggest that the postnatal caregiving environment may modulate the effects of PDE across development, influencing neurocognitive development.

Effectiveness of psychosocial interventions for reducing parental substance misuse

BACKGROUND

Parental substance use is a substantial public health and safeguarding concern. There have been a number of trials of interventions relating to substance-using parents that have sought to address this risk factor, with potential outcomes for parent and child.

OBJECTIVES

To assess the effectiveness of psychosocial interventions in reducing parental substance use (alcohol and/or illicit drugs, excluding tobacco).

SEARCH METHODS

We searched the following databases from their inception to July 2020: the Cochrane Drugs and Alcohol Group Specialised Register; CENTRAL; MEDLINE; Embase; PsycINFO; CINAHL; Applied Social Science (ASSIA); Sociological Abstracts; Social Science Citation Index (SSCI), Scopus, ClinicalTrials.gov, WHO ICTRP, and TRoPHI. We also searched key journals and the reference lists of included papers and contacted authors publishing in the field.

SELECTION CRITERIA

We included data from trials of complex psychosocial interventions targeting substance use in parents of children under the age of 21 years. Studies were only included if they had a minimum follow-up period of six months from the start of the intervention and compared psychosocial interventions to comparison conditions. The primary outcome of this review was a reduction in the frequency of parental substance use.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 22 unique studies with a total of 2274 participants (mean age of parents ranged from 26.3 to 40.9 years), examining 24 experimental interventions. The majority of studies intervened with mothers only (n = 16; 73%). Heroin, cocaine, and alcohol were the most commonly reported substances used by participants. The interventions targeted either parenting only (n = 13; 59%); drug and alcohol use only (n = 5; 23%); or integrated interventions which addressed both (n = 6; 27%). Half of the studies (n = 11; 50%) compared the experimental intervention to usual treatment. Other comparison groups were minimal intervention, attention controls, and alternative intervention. Eight of the included studies reported data relating to our primary outcome at 6- and/or 12-month follow-up and were included in a meta-analysis. We investigated intervention effectiveness separately for alcohol and drugs. Studies were found to be mostly at low or unclear risk for all 'Risk of bias' domains except blinding of participants and personnel and outcome assessment.  We found moderate-quality evidence that psychosocial interventions are probably more effective at reducing the frequency of parental alcohol misuse than comparison conditions at 6-month (mean difference (MD) -0.32, 95% confidence interval (CI) -0.51 to -0.13; 6 studies, 475 participants) and 12-month follow-up (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.03; 4 studies, 366 participants). We found a significant reduction in frequency of use at 12 months only (SMD -0.21, 95% CI -0.41 to -0.01; 6 studies, 514 participants, moderate-quality evidence). We examined the effect of the intervention type. We found low-quality evidence that psychosocial interventions targeting substance use only may not reduce the frequency of alcohol (6 months: SMD -0.35, 95% CI -0.86 to 0.16; 2 studies, 89 participants and 12 months: SMD -0.09, 95% CI -0.86 to 0.61; 1 study, 34 participants) or drug use (6 months: SMD 0.01, 95% CI -0.42 to 0.44; 2 studies; 87 participants and 12 months: SMD -0.08, 95% CI -0.81 to 0.65; 1 study, 32 participants). A parenting intervention only, without an adjunctive substance use component, may not reduce frequency of alcohol misuse (6 months: SMD -0.21, 95% CI -0.46 to 0.04, 3 studies; 273 participants, low-quality evidence and 12 months: SMD -0.11, 95% CI -0.64 to 0.41; 2 studies; 219 participants, very low-quality evidence) or frequency of drug use  (6 months: SMD 0.10, 95% CI -0.11 to 0.30; 4 studies; 407 participants, moderate-quality evidence and 12 months: SMD -0.13, 95% CI -0.52 to 0.26; 3 studies; 351 participants, very low-quality evidence). Parents receiving integrated interventions which combined both parenting- and substance use-targeted components may reduce alcohol misuse with a small effect size (6 months: SMD -0.56, 95% CI -0.96 to -0.16 and 12 months: SMD -0.42, 95% CI -0.82 to -0.03; 2 studies, 113 participants) and drug use (6 months: SMD -0.39, 95% CI -0.75 to -0.03 and 12 months: SMD -0.43, 95% CI -0.80 to -0.07; 2 studies, 131 participants). However, this evidence was of low quality. Psychosocial interventions in which the child was present in the sessions were not effective in reducing the frequency of parental alcohol or drug use, whilst interventions that did not involve children in any of the sessions were found to reduce frequency of alcohol misuse (6 months: SMD -0.47, 95% CI -0.76 to -0.18; 3 studies, 202 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use at 12-month follow-up (SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants). The quality of this evidence was low. Interventions appeared to be more often beneficial for fathers than for mothers. We found low- to very low-quality evidence of a reduction in frequency of alcohol misuse for mothers at six months only (SMD -0.27, 95% CI -0.50 to -0.04; 4 studies, 328 participants), whilst in fathers there was a reduction in frequency of alcohol misuse (6 months: SMD -0.43, 95% CI -0.78 to -0.09; 2 studies, 147 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use (6 months: SMD -0.31, 95% CI -0.66 to 0.04; 2 studies, 141 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants).

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that psychosocial interventions probably reduce the frequency at which parents use alcohol and drugs. Integrated psychosocial interventions which combine parenting skills interventions with a substance use component may show the most promise. Whilst it appears that mothers may benefit less than fathers from intervention, caution is advised in the interpretation of this evidence, as the interventions provided to mothers alone typically did not address their substance use and other related needs. We found low-quality evidence from few studies that interventions involving children are not beneficial.

Systematic Review of Community- and Home-Based Interventions to Support Parenting and Reduce Risk of Child Maltreatment Among Families With Substance-Exposed Newborns

Substance-exposed newborns (SENs) are at increased risk of child maltreatment, out-of-home placement, and poor health and developmental outcomes. The purpose of this systematic review is to synthesize existing research on community- and home-based interventions designed to improve parenting and reduce risk of maltreatment for families with SENs, applying a program logic framework. The review includes studies that used preexperimental, quasi-experimental, and experimental designs. Twelve interventions were identified. Of the nine studies that used more rigorous experimental or quasi-experimental designs, five showed positive effects on at least one parenting or child maltreatment outcome, although some studies showed high risk of bias. Full coherence among the intended participants, theory of change, and program components was observed for only two interventions. The findings suggest a need for more rigorous research to develop and test interventions that are grounded in theory and prior research and that address the unique needs of families with SENs.

Identifying Effective Components of Child Maltreatment Interventions: A Meta-analysis

There is a lack of knowledge about specific components that make interventions effective in preventing or reducing child maltreatment. The aim of the present meta-analysis was to increase this knowledge by summarizing findings on effects of interventions for child maltreatment and by examining potential moderators of this effect, such as intervention components and study characteristics. Identifying effective components is essential for developing or improving child maltreatment interventions. A literature search yielded 121 independent studies (N = 39,044) examining the effects of interventions for preventing or reducing child maltreatment. From these studies, 352 effect sizes were extracted. The overall effect size was significant and small in magnitude for both preventive interventions (d = 0.26, p < .001) and curative interventions (d = 0.36, p < .001). Cognitive behavioral therapy, home visitation, parent training, family-based/multisystemic, substance abuse, and combined interventions were effective in preventing and/or reducing child maltreatment. For preventive interventions, larger effect sizes were found for short-term interventions (0-6 months), interventions focusing on increasing self-confidence of parents, and interventions delivered by professionals only. Further, effect sizes of preventive interventions increased as follow-up duration increased, which may indicate a sleeper effect of preventive interventions. For curative interventions, larger effect sizes were found for interventions focusing on improving parenting skills and interventions providing social and/or emotional support. Interventions can be effective in preventing or reducing child maltreatment. Theoretical and practical implications are discussed.

Impact of Mindfulness-Based Parenting on Women in Treatment for Opioid Use Disorder

OBJECTIVES

Mothers with opioid use disorder are at high risk for maladaptive parenting. The present observational study aimed to measure the impact of a trauma-informed mindfulness-based parenting (MBP) intervention on quality of parenting behaviors of mothers primarily with opioid use disorders as well as examine associations between exposure to adverse childhood experiences and self-reported mindful parenting.

METHODS

A pretest posttest design was used with repeated measures. A total of 160 women were recruited from a substance use treatment program into the 12-week-long group-based intervention comprised didactic and experiential mindfulness activities. The Keys to Interactive Parenting Scale (KIPS) measured quality of parenting behavior, the Adverse Childhood Experiences Tool captured history of exposure to childhood trauma, and the Interpersonal Mindfulness in Parenting (IM-P) scale measured the degree of mindful parenting. Analyses were conducted using multilevel modeling.

RESULTS

The MBP intervention resulted in clinically significant improvements in KIPS total and all subscale scores and an IM-P total score. Data showed higher baseline Adverse Childhood Experiences and higher program attendance significantly predicted improved overall quality of parenting behaviors at a greater rate over time. Higher IM-P scores were associated with greater rate of improvement in KIPS total and all subscale scores.

CONCLUSIONS

Study findings suggest a trauma-informed MBP intervention for parenting women with opioid use disorders is associated with significant clinical improvements in quality of parenting behavior. Results of this model show promise in supporting parenting of mothers receiving treatment for opioid use disorders to enhance bonding and parenting.

Long-term effects of prenatal drug exposure on the neural correlates of memory at encoding and retrieval

The objective of the current study was to examine what stage of memory (encoding or retrieval) may be compromised in adolescents with a history of prenatal drug exposure (PDE) and how the effects of PDE on memory ability are substantiated at the neural level. To achieve this goal, we examined memory performance and associated brain activations in adolescents with and without a history of PDE via event-related fMRI during encoding and retrieval. Consistent with previous studies, we found that PDE subjects remembered fewer items than community comparison subjects. However, there were no differences in behavior after adjusting for correct rejections (i.e., d'). Novel extensions of previous work are findings that PDE is associated with changes in brain activation during memory encoding but not during retrieval. These results suggest that less optimal memory performance often observed in adolescents with a history of PDE may result from variations in encoding rather than retrieval processes.

Do preventive interventions for children of mentally ill parents work? Results of a systematic review and meta-analysis

PURPOSE OF REVIEW

The transgenerational transmission of mental disorders is one of the most significant causes of psychiatric morbidity. Several risk factors for children of parents with mental illness (COPMI) have been identified in numerous studies and meta-analyses.

RECENT FINDINGS

Many interventions have been developed for this high-risk group, but data about their efficacy are heterogeneous.

SUMMARY

The current meta-analysis reports on 96 articles including 50 independent samples from randomized controlled trials quantifying effects of preventive interventions for COPMI. Random effect models resulted in small, though significant Effect Sizes (ES) for programs enhancing the mother-infant interaction (ES = 0.26) as well as mothers' (ES = 0.33) and children's (ES = 0.31) behavior that proved to be stable over the 12-month follow-up, except for infants' behavior. Interventions for children/adolescents resulted in significant small effects for global psychopathology (ES = 0.13), as well as internalizing symptoms (ES = 0.17), and increased significantly over time, with externalizing symptoms reaching significance in the follow-up assessments as well (ES = 0.17). Interventions addressing parents and children jointly produced overall larger effects. Higher study quality was associated with smaller effects. There is a dearth of high quality studies that effectively reduce the high risk of COPMI for the development of mental disorders.

Interprofessional Teamwork and Collaboration Between Community Health Workers and Healthcare Teams: An Integrative Review

OBJECTIVES

Community Health Workers (CHWs) serve as a means of improving outcomes for underserved populations. However, their relationship within health care teams is not well studied. The purpose of this integrative review was to examine published research reports that demonstrated positive health outcomes as a result of CHW intervention to identify interprofessional teamwork and collaboration between CHWs and health care teams.

METHODS

A total of 47 studies spanning 33 years were reviewed using an integrative literature review methodology for evidence to support the following assumptions of effective interprofessional teamwork between CHWs and health care teams: (1) shared understanding of roles, norms, values, and goals of the team; (2) egalitarianism; (3) cooperation; (4) interdependence; and(5) synergy.

RESULTS

Of the 47 studies, 12 reported at least one assumption of effective interprofessional teamwork. Four studies demonstrated all 5 assumptions of interprofessional teamwork.

CONCLUSIONS

Four studies identified in this integrative review serve as exemplars for effective interprofessional teamwork between CHWs and health care teams. Further study is needed to describe the nature of interprofessional teamwork and collaboration in relation to patient health outcomes.

Prenatal drug exposure moderates the association between stress reactivity and cognitive function in adolescence

Prenatal drug exposure (PDE) can undermine subsequent health and development. In a prospective longitudinal study we examine whether PDE moderates the link between stress reactivity and cognitive functioning in adolescence. Participants were 76 prenatally drug-exposed and 61 nonexposed (NE) community comparison African American youth (50% male, mean age 14.17 years) living in an urban setting. All participants completed neuropsychological and academic achievement tests (Children's Memory Scales, the California Verbal Learning Test - Children's version and the Wide Range Achievement Test 4) over the course of 1 day in a laboratory setting. Two mild stressors (Balloon Analog Risk Task - Youth and Behavioral Indicator of Resilience to Distress) were administered, with saliva samples (assayed for cortisol) collected pre- and poststress task. A higher percentage in the NE group, compared to the PDE group (26% vs. 12%, χ(2) = 4.70, d.f. = 1, n = 137, p = 0.03), exhibited task-related increases in salivary cortisol. PDE moderated the association between stress reactivity and 11 of 15 cognitive performance scales. In each case, the NE stress reactive group had better cognitive performance than either the NE lower cortisol reactive group or the PDE group regardless of stress reactivity status. Stress-related reactivity and regulation of the hypothalamic-pituitary-adrenal axis in adolescence may be disrupted by PDE, and the disruption may be linked to lower cognitive performance.

Relations among prospective memory, cognitive abilities, and brain structure in adolescents who vary in prenatal drug exposure

This investigation examined how prospective memory (PM) relates to cognitive abilities (i.e., executive function, attention, working memory, and retrospective memory) and brain structure in adolescents who vary in prenatal drug exposure (PDE). The sample consisted of 105 (55 female and 50 male) urban, primarily African American adolescents (mean age=15.5 years) from low socioeconomic status (SES) families. Approximately 56% (n=59) were prenatally exposed to drugs (heroin and/or cocaine) and 44% (n=46) were not prenatally exposed, but the adolescents were similar in age, gender, race, and SES. Executive functioning, attentional control, working memory, retrospective memory, and overall cognitive ability were assessed by validated performance measures. Executive functioning was also measured by caregiver report. A subset of 52 adolescents completed MRI (magnetic resonance imaging) scans, which provided measures of subcortical gray matter volumes and thickness of prefrontal, parietal, and temporal cortices. Results revealed no differences in PM performance by PDE status, even after adjusting for age and IQ. Executive function, retrospective memory, cortical thickness in frontal and parietal regions, and volume of subcortical regions (i.e., putamen and hippocampus) were related to PM performance in the sample overall, even after adjusting for age, IQ, and total gray matter volume. Findings suggest that variations in PM ability during adolescence are robustly related to individual differences in cognitive abilities, in particular executive function and retrospective memory, and brain structure, but do not vary by PDE status.

Community engagement to reduce inequalities in health: a systematic review, meta-analysis and economic analysis

Background

Community engagement has been advanced as a promising way of improving health and reducing health inequalities; however, the approach is not yet supported by a strong evidence base.

Objectives

To undertake a multimethod systematic review which builds on the evidence that underpins the current UK guidance on community engagement; to identify theoretical models underpinning community engagement; to explore mechanisms and contexts through which communities are engaged; to identify community engagement approaches that are effective in reducing health inequalities, under what circumstances and for whom; and to determine the processes and costs associated with their implementation.

Data sources

Databases including the Cochrane Database of Systematic Reviews (CDSR), The Campbell Library, the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) database, the NHS Economic Evaluation Database (NHS EED) and EPPI-Centre’s Trials Register of Promoting Health Interventions (TRoPHI) and Database of Promoting Health Effectiveness Reviews (DoPHER) were searched from 1990 to August 2011 for systematic reviews and primary studies. Trials evaluating community engagement interventions reporting health outcomes were included.

Review methods

Study eligibility criteria: published after 1990; outcome, economic, or process evaluation; intervention relevant to community engagement; written in English; measured and reported health or community outcomes, or presents cost, resource, or implementation data characterises study populations or reports differential impacts in terms of social determinants of health; conducted in an Organisation for Economic Co-operation and Development (OECD) country. Study appraisal: risk of bias for outcome evaluations; assessment of validity and relevance for process evaluations; comparison against an economic evaluation checklist for economic evaluations. Synthesis methods: four synthesis approaches were adopted for the different evidence types: theoretical, quantitative, process, and economic evidence.

Results

The theoretical synthesis identified key models of community engagement that are underpinned by different theories of changes. Results from 131 studies included in a meta-analysis indicate that there is solid evidence that community engagement interventions have a positive impact on health behaviours, health consequences, self-efficacy and perceived social support outcomes, across various conditions. There is insufficient evidence – particularly for long-term outcomes and indirect beneficiaries – to determine whether one particular model of community engagement is likely to be more effective than any other. There are also insufficient data to test the effects on health inequalities, although there is some evidence to suggest that interventions that improve social inequalities (as measured by social support) also improve health behaviours. There is weak evidence from the effectiveness and process evaluations that certain implementation factors may affect intervention success. From the economic analysis, there is weak but inconsistent evidence that community engagement interventions are cost-effective. By combining findings across the syntheses, we produced a new conceptual framework.

Limitations

Differences in the populations, intervention approaches and health outcomes made it difficult to pinpoint specific strategies for intervention effectiveness. The syntheses of process and economic evidence were limited by the small (generally not rigorous) evidence base.

Conclusions

Community engagement interventions are effective across a wide range of contexts and using a variety of mechanisms. Public health initiatives should incorporate community engagement into intervention design. Evaluations should place greater emphasis on long-term outcomes, outcomes for indirect beneficiaries, process evaluation, and reporting costs and resources data. The theories of change identified and the newly developed conceptual framework are useful tools for researchers and practitioners. We identified trends in the evidence that could provide useful directions for future intervention design and evaluation.

Funding

The National Institute for Health Research Public Health Research programme.

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.

THE EFFECTIVENESS OF AN ATTACHMENT-BASED INTERVENTION IN PROMOTING FOSTER MOTHERS' SENSITIVITY TOWARD FOSTER INFANTS

Infants in foster care need sensitive, responsive caregivers to promote their healthy outcomes. The current study examined the effectiveness of the Attachment and Biobehavioral Catch-up Intervention, a short-term, targeted, attachment-based intervention program designed to promote sensitive caregiving behavior among foster mothers. Ninety-six foster mother-infant dyads participated in this study; 44 dyads were assigned to the Attachment and Biobehavioral Catch-up Intervention, and 52 dyads were assigned to a control intervention. Results of hierarchical linear modeling indicated that foster mothers who were assigned to the Attachment and Biobehavioral Catch-up Intervention showed greater improvements in their sensitivity from pre- to postintervention assessment time points when compared with foster mothers who were assigned to the control intervention. We conclude that a short-term, targeted, attachment-based intervention is effective in changing foster mothers' responsiveness to their foster infants, which is critical for foster infants' healthy socioemotional adjustment.

Postpartum health promotion interventions: a systematic review

BACKGROUND

The postpartum period is a time of significant transition when women may discontinue positive health behaviors adopted during pregnancy. Little is known about the effectiveness of health promotion interventions targeting postpartum women.

OBJECTIVE

The aim of this study was to synthesize the published evidence from randomized controlled trials conducted in the United States on the effectiveness of interventions promoting maternal health in the first year after childbirth.

METHODS

Studies conducted in the United States and published from 1999 through May 2011 were identified in MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO and reviewed.

RESULTS

Eleven studies were identified measuring health promotion behaviors as an outcome. Nine of the 11 targeted at-risk groups. Methodological problems included incomplete description of the intervention, steps taken to ensure representativeness of the sample, and identification and control of potential confounders. Diverse aspects of health promotion were addressed, the length of participant involvement differed, and the effectiveness of the interventions varied.

DISCUSSION

Further research is needed to design interventions focused on promoting health in the general population of postpartum mothers.

Memory ability and hippocampal volume in adolescents with prenatal drug exposure

The objective of the present study was to examine the influence of prenatal drug exposure (PDE) on memory performance and supporting brain structures (i.e., hippocampus) during adolescence. To achieve this goal, declarative memory ability and hippocampal volume were examined in a well-characterized sample of 138 adolescents (76 with a history of PDE and 62 from a non-exposed comparison group recruited from the same community, mean age=14 years). Analyses were adjusted for: age at time of the assessments, gender, IQ, prenatal exposure to alcohol and tobacco, and indices of early childhood environment (i.e., caregiver depression, potential for child abuse, and number of caregiver changes through 7 years of age). Results revealed that adolescents with a history of PDE performed worse on the California Verbal Learning Test-Child Version (CVLT-C), and story recall from the Children's Memory Scale (CMS), and had larger hippocampal volumes, even after covariate adjustment. Hippocampal volume was negatively correlated with memory performance on the CVLT-C, with lower memory scores associated with larger volumes. These findings provide support for long-term effects of PDE on memory function and point to neural mechanisms that may underlie these outcomes.

Prenatal drug exposure and peer victimization in early adolescence: testing childhood anxiety/depression and aggression as possible mediators

OBJECTIVE

Children who are prenatally exposed to drugs may be at risk for emotion dysregulation, including childhood anxiety/depression and aggression, potentially increasing their risk for peer victimization. The objectives of this study were to investigate how prenatal drug exposure relates to adolescent peer victimization and the mediating effects of childhood anxiety/depression and aggression.

METHODS

Seventy-six prenatally drug exposed (PDE) and 38 nonexposed (NE) adolescent-caregiver dyads followed since birth and middle childhood, respectively, participated in an evaluation during adolescence. In middle childhood, caregivers reported on their child's anxiety/depression and aggression, and children reported on violence exposure. In adolescence, caregivers and adolescents responded to a parallel single-item measure of peer victimization. Analyses were conducted using multivariate linear and logistic regression models, adjusting for covariates, including violence exposure.

RESULTS

One-third (33.3%, n = 35) of the sample endorsed peer victimization: 40.8% PDE and 17.6% NE, p = .01. In middle childhood, PDE youth had more aggressive behaviors (11.92 vs 7.45, p < .01) and anxiety/depression symptoms (3.43 vs 1.76, p < .01) than NE youth. Anxious/depressed behavior during childhood mediated the association between prenatal drug exposure and adolescent peer victimization. Aggression was not a significant mediator.

CONCLUSIONS

The consequences of prenatal drug exposure extend into adolescence. Prenatal drug exposure may interfere with emotion regulation, resulting in anxious/depressed behavior during childhood and significantly increasing the risk for peer victimization during adolescence, even in the presence of violence exposure. Strategies to reduce anxious/depressed behavior among children with a history of prenatal drug exposure may reduce adolescent peer victimization.

Theory! The missing link in understanding the performance of neonate/infant home-visiting programs to prevent child maltreatment: a systematic review

CONTEXT

Home-visiting programs have been offered for more than sixty years to at-risk families of newborns and infants. But despite decades of experience with program delivery, more than sixty published controlled trials, and more than thirty published literature reviews, there is still uncertainty surrounding the performance of these programs. Our particular interest was the performance of home visiting in reducing child maltreatment.

METHODS

We developed a program logic framework to assist in understanding the neonate/infant home-visiting literature, identified through a systematic literature review. We tested whether success could be explained by the logic model using descriptive synthesis and statistical analysis.

FINDINGS

Having a stated objective of reducing child maltreatment-a theory or mechanism of change underpinning the home-visiting program consistent with the target population and their needs and program components that can deliver against the nominated theory of change-considerably increased the chance of success. We found that only seven of fifty-three programs demonstrated such consistency, all of which had a statistically significant positive outcome, whereas of the fifteen that had no match, none was successful. Programs with a partial match had an intermediate success rate. The relationship between program success and full, partial or no match was statistically significant.

CONCLUSIONS

Employing a theory-driven approach provides a new way of understanding the disparate performance of neonate/infant home-visiting programs. Employing a similar theory-driven approach could also prove useful in the review of other programs that embody a diverse set of characteristics and may apply to diverse populations and settings. A program logic framework provides a rigorous approach to deriving policy-relevant meaning from effectiveness evidence of complex programs. For neonate/infant home-visiting programs, it means that in developing these programs, attention to consistency of objectives, theory of change, target population, and program components is critical.

Home visits during pregnancy and after birth for women with an alcohol or drug problem

BACKGROUND

One potential method of improving outcome for pregnant or postpartum women with a drug or alcohol problem is with home visits.

OBJECTIVES

To determine the effects of home visits during pregnancy and/or after birth for women with a drug or alcohol problem.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to 30 November 2011), EMBASE (1980 to 30 November 2011), CINAHL (1982 to 30 November 2011) and PsycINFO (1974 to 30 November 2011) supplemented by searches of citations from previous reviews and trials and contact with experts.

SELECTION CRITERIA

Studies using random or quasi-random allocation of pregnant or postpartum women with a drug or alcohol problem to home visits. Trials enrolling high-risk women of whom more than 50% were reported to use drugs or alcohol were also eligible.

DATA COLLECTION AND ANALYSIS

Review authors performed assessments of trials independently. We performed statistical analyses using fixed-effect and random-effects models where appropriate.

MAIN RESULTS

Seven studies (reporting 803 mother-infant pairs) compared home visits mostly after birth with no home visits. Visitors included community health nurses, paediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African-American women. Several studies had significant methodological limitations. There was no significant difference in continued illicit drug use (three studies, 384 women; risk ratio (RR) 1.05, 95% confidence interval (CI) 0.89 to 1.24), continued alcohol use (three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46), failure to enrol in a drug treatment program (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10), incomplete six-month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95% CI 0.91 to 1.32), the Bayley Mental Development Index (three studies, 199 infants; mean difference 2.89, 95% CI -1.17 to 6.95) or Psychomotor Index (MD 3.14, 95% CI -0.03 to 6.32), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), infants not in care of biological mother (two studies, 254 infants; RR 0.83, 95% CI 0.50 to 1.39), non-accidental injury and non-voluntary foster care (two studies, 254 infants; RR 0.16, 95% CI 0.02 to 1.23) or infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to 4.16). Individual studies reported a significant reduction in involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74) and failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the routine use of home visits for pregnant or postpartum women with a drug or alcohol problem. Further large, high-quality trials are needed.

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

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

Children of substance-using mothers: child health engagement and child protection outcomes

AIM

Maternal substance use has been associated with a range of child risk factors. The study investigated the relationship between engagement with child health services and child protection outcomes for children of substance-using mothers.

METHODS

The sample comprised 119 children of mothers who disclosed opiate, amphetamine or methadone use during a maternity admission between 2000 and 2003. Statutory child protection agency and child health engagement information for the first 2 years of life was obtained. The relationship between type of maternal substance use, child health engagement and child protection outcomes was examined.

RESULTS

Of study group infants, 72% were engaged with child health services during the first 2 years of life. Chi-squared analysis showed no significant relationship between child health engagement and child protection reports. Child health engagement was associated with decreased substantiated child protection notifications for children of methadone using mothers, but not for children of illicit substance users.

CONCLUSIONS

Almost a quarter of identified children of substance-using mothers are not accessing standard child health services in their first 2 years of life. This study provides support for increased attention to the provision of child health services for children of methadone using mothers. Further research into effective intervention strategies for children of illicit substance-using mothers is indicated.

Promoting secure attachment: evaluation of the effectiveness of an early intervention pilot programme with mother-infant dyads in Santiago, Chile

BACKGROUND

Research indicates that the early attachment patterns of babies could influence their socio-emotional development and prevent the emergence of problematic behaviours in the child later in life. Many studies in the field of early attachment interventions have promoted a secure attachment bond between mother and infant. The purpose of this study was to evaluate the effectiveness of an early pilot intervention programme designed to promote a secure attachment bond in mother-infant dyads belonging to a population seeking regular treatment at urban health centres in Santiago, Chile.

METHODS

Primipara mothers were randomly assigned to two intervention conditions: a secure attachment promotion programme (experimental group = 43) or an educational talk (control group = 29). The Strange Situation Assessment was used to collect data on the attachment patterns of babies.

RESULTS

The results show that after the intervention, there were more babies with secure attachment in the experimental group than in the control group.

CONCLUSIONS

These findings represent a preliminary step towards evaluating interventions aimed at promoting secure attachment in Chilean mother-child dyads. While the effect of the intervention is not significant, the effect size obtained is respectable and consistent with other meta-analytic findings.

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

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

Outcomes and costs of community health worker interventions: a systematic review

OBJECTIVES

We conducted a systematic review on outcomes and costs of community health worker (CHW) interventions. CHWs are increasingly expected to improve health outcomes cost-effectively for the underserved.

RESEARCH DESIGN

We searched Medline, Cochrane Collaboration resources, and the Cumulative Index to Nursing and Allied Health Literature for studies conducted in the United States and published in English from 1980 through November 2008. We dually reviewed abstracts, full-text articles, data abstractions, quality ratings, and strength of evidence grades and resolved disagreements by consensus.

RESULTS

We included 53 studies on outcomes of CHW interventions and 6 on cost or cost-effectiveness. For outcomes, limited evidence (5 studies) suggests that CHW interventions can improve participant knowledge compared with alternative approaches or no intervention. We found mixed evidence for participant behavior change (22 studies) and health outcomes (27 studies). Some studies suggested that CHW interventions can result in greater improvements in participant behavior and health outcomes compared with various alternatives, but other studies suggested that CHW interventions provide no statistically different benefits than alternatives. We found low or moderate strength of evidence suggesting that CHWs can increase appropriate health care utilization for some interventions (30 studies). Six studies with economic information yielded insufficient data to evaluate the cost-effectiveness of CHW interventions relative to other interventions.

CONCLUSIONS

CHWs can improve outcomes for underserved populations for some health conditions. The effectiveness of CHWs in many health care areas requires further research that addresses the methodologic limitations of prior studies and that contributes to translating research into practice.

The role of mesocorticolimbic dopamine in regulating interactions between drugs of abuse and social behavior

The use of addictive drugs can have profound short- and long-term consequences on social behaviors. Similarly, social experiences and the presence or absence of social attachments during early development and throughout life can greatly influence drug intake and the susceptibility to drug abuse. The following review details this reciprocal interaction, focusing on common drugs of abuse (e.g., psychostimulants, opiates, alcohol and nicotine) and social behaviors (e.g., maternal, sexual, play, aggressive and bonding behaviors). The neural mechanisms underlying this interaction are discussed, with a particular emphasis on the involvement of the mesocorticolimbic dopamine system.

Concurrent Treatment of Substance Abuse, Child Neglect, Bipolar Disorder, Post-Traumatic Stress Disorder, and Domestic Violence: A Case Examination Involving Family Behavior Therapy

High rates of co-occurrence between substance abuse and child neglect have been well documented and especially difficult to treat. As a first step in developing a comprehensive evidence-based treatment for use in this population, the present case examination underscores Family Behavior Therapy (FBT) in the treatment of a mother who evidenced Substance Dependence, child neglect, Post-Traumatic Stress Disorder, Bipolar I Disorder, and domestic violence. Utilizing psychometrically validated self-report inventories and objective urinalysis, treatment was found to result in the cessation of substance use, lower risk of child maltreatment, improved parenting attitudes and practices, and reduced instances of violence in the home. The importance of utilizing validity scales in the assessment of referrals from child welfare settings is discussed, and future directions are reported in light of the results.

Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases

BACKGROUND

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions.

OBJECTIVES

To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases.

SEARCH STRATEGY

For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers.

SELECTION CRITERIA

Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained.

MAIN RESULTS

Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective.

AUTHORS' CONCLUSIONS

LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

Parental mental representations during late pregnancy and early parenthood following assisted reproductive technology

OBJECTIVE

To evaluate the relationship between assisted reproduction technology (ART) and parental mental representations during late pregnancy and early parenthood.

STUDY DESIGN

Women (n=25) following ART pregnancies were compared with their partners (n=23) and with women following spontaneous conceptions (n=39). Subjects were interviewed on mental representations at late gestation and three months postpartum.

RESULTS

Socio-demographic and obstetrical characteristics were similar between groups. ART women tend to decrease scores of intensity of investment from before to after delivery. During pregnancy and postpartum, ambivalent representations were more often present and well-integrated representations were less often present among ART women as compared with non-ART women. ART women had significantly more ambivalent representations that persisted at three months postpartum, and men had more disengaged representations.

CONCLUSIONS

A greater desire for pregnancy exists in ART women which might not always coincide with a desire for maternity. ART men, however, manifest greater disengagement from the entire child project.

The effect of prenatal drug exposure and caregiving context on children's performance on a task of sustained visual attention

OBJECTIVES

Three groups of children from low-income, urban environments were examined to determine the effects of prenatal drug exposure (PDE) and caregiving environment on sustained visual attention (SVA) at 7 years of age.

METHODS

Drug-exposed children remaining in maternal care (n = 43), drug-exposed children placed in nonmaternal care (n = 45), and community comparison (CC) children (n = 56) were administered a battery of neurocognitive tests, including the Conners' Continuous Performance Test (CPT).

RESULTS

PDE children remaining in maternal care displayed more omission errors than CC children. PDE children in nonmaternal care had intermediate scores that did not differ significantly from PDE children in maternal care or CC children. There were no group differences with respect to commission errors or reaction time. CPT errors of omission and commission were significantly correlated with parent-reported attention problems and academic achievement scores.

CONCLUSIONS

PDE in the context of care provided by a maternal caregiver with persistent drug use patterns may contribute to problems in children's SVA at school-age. As parental drug abuse can interfere with the provision of early care, children raised in a drug-using context may be highly vulnerable to problems with self-regulation, including sustained attention. SVA problems may contribute to subsequent academic and behavioral problems as demands for concentration and sustained effort increase throughout childhood. Children who have been prenatally exposed to drugs or raised in a drug-using household may benefit from early intervention services to avoid problems in SVA that may interfere with subsequent neurocognitive functioning and academic performance.

Substance abuse interventions for parents involved in the child welfare system: evidence and implications

As child welfare systems across the country face the problem of parental substance abuse, there is an increasing need to understand the types of treatment approaches that are most effective for substance-abusing parents in the child welfare system-the majority of whom are mothers. This structured review of the literature focuses on evidence related to two areas: (1) individual-level interventions designed to assist mothers and women in addressing their substance abuse problems, and (2) system-level interventions designed to improve collaboration and coordination between the child welfare system and the alcohol and other drug system. Overall, research suggests the following program components may be effective with substance-abusing women with children: (1) Women-centered treatment that involves children, (2) Specialized health and mental health services, (3) Home visitation services, (4) Concrete assistance, (5) Short-term targeted interventions, and (6) Comprehensive programs that integrate many of these components. Research also suggests that promising collaborative models between the child welfare system (CWS) and the alcohol and other drug (AOD) system typically include the following core elements: (1) Out-stationing AOD workers in child welfare offices, (2) Joint case planning, (3) Using official committees to guide collaborative efforts, (4) Training and cross-training, (5) Using protocols for sharing confidential information, and (6) Using dependency drug courts. Although more rigorous research is needed on both individual-level and system-level substance abuse interventions for parents involved in the child welfare system, the integration of individual-level interventions and system-level approaches is a potentially useful practice approach with this vulnerable population.

Parenting Interventions for Drug-Dependent Mothers and Their Young Children: The Case for an Attachment-Based Approach

Maternal substance abuse is the most common factor involved when children come to the attention of the child welfare system. Although there is a clear need for clinical trials to evaluate parenting interventions for drug-dependent women, few studies to date have systematically examined the efficacy of interventions for this population. We first review six published reports of outpatient interventions that aimed to enhance the caregiving skills of substance-abusing mothers caring for children between birth and 5 years of age. After discussing implications of these preliminary studies, we then describe an attachment-based intervention that addresses these implications and has demonstrated preliminary feasibility in a pilot trial.

Substance abuse treatment and the recurrence of maltreatment among caregivers with children living at home: A propensity score analysis

Policy and programmatic initiatives of the last decade have focused on increased coordination of services and expansion of prompt substance abuse treatment for mothers initially involved with child welfare services (CWS). Yet, little evidence has been amassed concerning the implications of this approach on the recurrent need for CWS. Data are from a large national probability sample of children and their caregivers involved with CWS following an allegation of maltreatment. Data include the recurrence of maltreatment reports for this group of children who remain at home. Selected from 1,101 caregivers with an indicated substance abuse problem, a group of 224 clients who did not receive services were compared with 224 treated clients. Event history analyses showed that clients who received substance abuse treatment were nearly twice as likely to have another child abuse report within 18 months. Reasons why participation in substance abuse treatment may result in greater involvement with CWS are posited.

Home visits during pregnancy and after birth for women with an alcohol or drug problem

BACKGROUND

One potential method of improving outcome for pregnant or postpartum women with a drug or alcohol problem is with home visits.

OBJECTIVES

To determine the effects of home visits during pregnancy and/or after birth for pregnant women with a drug or alcohol problem.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Trials Register (30 April 2004), CENTRAL (The Cochrane Library, Issue 2, 2004), MEDLINE (1966 to April 2004), EMBASE (1980 to week 16, 2004), CINAHL (1982 to April 2004), PsycINFO (1974 to April 2004), citations from previous reviews and trials, and contacted expert informants.

SELECTION CRITERIA

Studies using random or quasi-random allocation of pregnant or postpartum women with a drug or alcohol problem to home visits. Trials enrolling high-risk women of whom more than 50% were reported to use drugs or alcohol were also eligible.

DATA COLLECTION AND ANALYSIS

Assessments of trials were performed independently by all review authors. Statistical analyses were performed using fixed and random-effects models where appropriate.

MAIN RESULTS

Six studies (709 women) compared home visits after birth with no home visits. None provided a significant antenatal component of home visits. The visitors included community health nurses, pediatric nurses, trained counsellors, paraprofessional advocates, midwives and lay African-American women. Most studies had methodological limitations, particularly large losses to follow up. There were no significant differences in continued illicit drug use (2 studies, 248 women; relative risk (RR) 0.95, 95% confidence interval (CI) 0.75 to 1.20), continued alcohol use (RR 1.08, 95% CI 0.83 to 1.41) failure to enrol in a drug treatment program (2 studies, 211 women; RR 0.45 95% CI 0.10 to 1.94). There was no significant difference in the Bayley MDI (3 studies, 199 infants; weighted mean difference 2.89, 95% CI -1.17 to 6.95) or Psychomotor Index (WMD 3.14, 95% CI -0.03 to 6.32). Other outcomes reported by one study only included breastfeeding at six months (RR 1.00, 95% CI 0.81 to 1.23), incomplete six-month infant vaccination schedule (RR 1.07, 95% CI 0.58 to 1.96), non-accidental injury and non-voluntary foster care (RR 0.16, 95% CI 0.02 to 1.23), failure to use postpartum contraception (RR 0.41, 95% CI 0.20 to 0.82), child behavioural problems (RR 0.46, 95% CI 0.21 to 1.01), and involvement with child protective services (RR 0.38, 95% CI 0.20 to 0.74).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the routine use of home visits for women with a drug or alcohol problem. Further large, high-quality trials are needed, and women's views on home visiting need to be assessed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lay health workers in primary and community health care

BACKGROUND

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions.

OBJECTIVES

To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained.

MAIN RESULTS

Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions.

AUTHORS' CONCLUSIONS

LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

The impact of motivational interviewing on substance abuse treatment retention: A randomized control trial of women involved with child welfare

Previous studies have supported the efficacy of Motivational Interviewing (MI) in increasing treatment engagement and retention among people with substance abuse disorders. However, few studies have assessed the impact of MI with coerced populations, particularly women referred to drug abuse treatment by child welfare due to prenatal drug use. Seventy-one such women who used drugs during pregnancy were randomly assigned to either receive three MI sessions or to watch two educational videos and participate in a home visit. Treatment retention group attendance and random urine analysis results were evaluated in these women during the first 8 weeks of treatment. No differences were found between the two conditions on these variables. Possible reasons for these negative findings are discussed, as are ideas for future research with coerced populations.

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

AIM

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Developmental outcome of drug-exposed children through 30 months: a comparison of Bayley and Bayley-II

This study examined the effects of the Bayley Scales of Infant Development (BSID) version on developmental outcomes among drug-exposed children, some of whom received an intervention. Developmental outcome was evaluated with the BSID at 12 and 18 months and with the BSID-II at 24 and 30 months. In the repeated measures analyses, children scored higher on the BSID Mental Developmental Index (MDI; p < .01) and Psychomotor Developmental Index (PDI; p < .01) than on the BSID-II MDI and PDI. Version x Time (p < .01) and Version x Group (p < .01) interactions were also found for the MDI but not the PDI. PDI scores decreased on both the BSID and the BSID-II (p < .01). Over the first 2 years postpartum, mean MDI and PDI scores decreased among these high-risk, drug-exposed children.

Cumulative environmental risk in substance abusing women: early intervention, parenting stress, child abuse potential and child development

OBJECTIVE

To assess the relationship between cumulative environmental risks and early intervention, parenting attitudes, potential for child abuse and child development in substance abusing mothers.

METHOD

We studied 161 substance-abusing women, from a randomized longitudinal study of a home based early intervention, who had custody of their children through 18 months. The intervention group received weekly home visits in the first 6 months and biweekly visits from 6 to 18 months. Parenting stress and child abuse potential were assessed at 6 and 18 months postpartum. Children's mental and motor development (Bayley MDI and PDI) and language development (REEL) were assessed at 6, 12, and 18 months postpartum. Ten maternal risk factors were assessed: maternal depression, domestic violence, nondomestic violence, family size, incarceration, no significant other in home, negative life events, psychiatric problems, homelessness, and severity of drug use. Level of risk was recoded into four categories (2 or less, 3, 4, and 5 or more), which had adequate cell sizes for repeated measures analysis.

DATA ANALYSIS

Repeated measures analyses were run to examine how level of risk and group (intervention or control) were related to parenting stress, child abuse potential, and children's mental, motor and language development over time.

RESULTS

Parenting stress and child abuse potential were higher for women with five risks or more compared with women who had four or fewer risks; children's mental, motor, and language development were not related to level of risk. Children in the intervention group had significantly higher scores on the PDI at 6 and 18 months (107.4 vs. 103.6 and 101.1 vs. 97.2) and had marginally better scores on the MDI at 6 and 12 months (107.7 vs. 104.2 and 103.6 vs. 100.1), compared to the control group.

CONCLUSION

Compared to drug-abusing women with fewer than five risks, women with five or more risks found parenting more stressful and indicated greater inclination towards abusive and neglectful behavior, placing their infants at increased risk for poor parenting, abuse and neglect. Early home-based intervention in high-risk families may be beneficial to infant development.

Less is more: meta-analyses of sensitivity and attachment interventions in early childhood

Is early preventive intervention effective in enhancing parental sensitivity and infant attachment security, and if so, what type of intervention is most successful? Seventy studies were traced, producing 88 intervention effects on sensitivity (n = 7,636) and/or attachment (n = 1,503). Randomized interventions appeared rather effective in changing insensitive parenting (d = 0.33) and infant attachment insecurity (d = 0.20). The most effective interventions used a moderate number of sessions and a clear-cut behavioral focus in families with, as well as without, multiple problems. Interventions that were more effective in enhancing parental sensitivity were also more effective in enhancing attachment security, which supports the notion of a causal role of sensitivity in shaping attachment.

Ongoing maternal drug use, parenting attitudes, and a home intervention: effects on mother-child interaction at 18 months

This prospective study examined the effects of ongoing maternal drug use, parenting attitudes, and a home-based intervention on mother-child interaction among drug-using women and their children. At 2 weeks postpartum, mothers and infants were randomly assigned to either an Intervention (n = 67) or Control (n = 64) Group. Intervention families received weekly visits until 6 months postpartum and biweekly visits from 6 to 18 months by trained lay visitors. The home intervention was designed to increase maternal empowerment and promote child development. Control families received brief monthly tracking visits. Mother-child interaction was evaluated at 18 months through observation of play. Mothers who continued to use cocaine and/or heroin had lower competence scores (p <.05); poor parenting attitude was also associated with lower competence scores during mother-child interaction (p <.05). Although the intervention had no measured effect, ongoing maternal drug use and poor parenting attitudes were associated with less optimal maternal behavior during mother-child interaction.