Abstract
Background
Mothers who are dually-diagnosed with HIV/AIDS and drug abuse are particularly burdened and vulnerable to loss of child custody.
Objectives
This study explores factors associated with child custody loss among HIV+ women in drug abuse recovery, and compares mothers who have custody of their children to mothers who do not have custody of all of their children.
Methods
Descriptive analyses were conducted on 68 HIV+ mothers in drug recovery, 46% who had custody of all of their children, and 54% who did not.
Results
The lost-custody group was less likely to be employed and had more history of violent impulses and arrest, particularly on drug charges. The groups reported similar recent and lifetime drug use patterns, but the custody group had received more drug treatment. Post-hoc analyses found the lost-custody group had lower rates of participation in the interventions offered in the parent clinical trial and higher avoidant coping.
Conclusions
The sample in the current study supports that HIV+ women in drug recovery are at high risk of loss of child custody. Non-adherence to available treatment seems to be associated with loss of child custody.
Scientific significance
Results suggest the need for further research and active treatment outreach for this population.
Keywords: Child custody, HIV/AIDS, substance abuse, women
INTRODUCTION
The destructive impact of HIV/AIDS on the family unit has been well documented (1, 2). HIV/AIDS disrupts family structures (3-5), parental roles (6), and mother–child relationships (7, 8). In a nationally-representative study of HIV+ parents (N = 538), Cowgill et al. found that less than half (47%) of the children were in their parents’ custody (9). Further, an analysis of over 4,000 children of women entering treatment for alcohol or drug abuse found that 33% were not in their mother’s custody (10). Parents who are dually-diagnosed with HIV/AIDS and drug abuse are particularly burdened and vulnerable (11). In a sample of HIV+ current and former drug-using parents in Baltimore, Knowlton found that only one-third (34%) had custody of their children (12).
Research on parental disruption for HIV+ drug-abusing mothers points to substance abuse as a more prominent risk factor than HIV-related issues. A study of over 100 adolescent children of drug and alcohol abusing mothers found no significant differences in rates of family disruption, history of abuse, and mental health problems between the children of HIV infected versus uninfected mothers (13). Cowgill et al. found that among the reasons cited by HIV+ parents for custody loss, drug use was the most common (62%) (9).
The current study explores factors associated with child custody loss among HIV+ women in drug abuse recovery, and compares mothers who have custody of their children to mothers who do not have custody of all of their children.
MATERIALS AND METHODS
Sample
Participants in this study are 68 HIV+ women in drug recovery who were eligible for a randomized trial to test the efficacy of Structural Ecosystems Therapy (14, 15), a family-based intervention for improving medication adherence and reducing relapse. The current study includes those women who reported having minor children. To be eligible for the randomized trial, women had to have been HIV-1 seropositive and met criteria for recommending antiretroviral therapy (16), at least 18 years of age, and met the DSM-IV requirements for abuse or dependence on an illegal substance within the last two years (with cocaine as either the primary or secondary drug of abuse). Women were excluded if they had a DSM-IV diagnosis of current abuse or dependence on an illegal substance within the 30 days prior to study enrollment, were in a phase of institutionalization in which outside contact was prohibited, or had a CD4 cell count of less than 50. The study was open to English- or Spanish-speaking women of all ethnic/racial groups.
Measures
Demographic and family characteristics were gleaned from the woman’s self-report on demographic and family identification forms which asked the women to identify: 1) all the people in her home; 2) any children who did not live with her; 3) the primary person(s) who helped take care of her children; 4) current spouse/partner; and 5) anyone else who she considered a major source of support. In reference to her children, women were asked if she was raising the child and who was the legal custodian of the child.
DSM–IV substance use diagnoses were derived using the Composite International Diagnostic Interview (CIDI), a comprehensive, standardized instrument for the assessment of mental disorders (17). Drug use, mental health, and arrest history were measured using the Addiction Severity Index (ASI) (18). For the purposes of this study, we reported both on individual items of lifetime drug use and the drug use composite scale which is based on respondent’s experiences in the past 30 days. Cronbach’s alpha for the ASI drug use composite subscale was .65.
Lifetime arrest history and psychological symptoms were also extracted from ASI items. Psychological distress was measured using the Global Severity Index of the Brief Symptom Inventory (BSI) (19), a 53-item questionnaire that assesses the respondent’s psychological symptom patterns in the past seven days, which had a Cronbach’s alpha in the current sample of .97. Depressive symptoms were measured with the depression subscale of the Structured Interview Guide for the Hamilton Depression and Anxiety (SIGH-AD) (20), which had a Cronbach’s alpha of .80 in the current sample.
HIV Viral Load Blood HIV-1 RNA levels were quantified using reverse transcriptase polymerase chain reaction (RT-PCR) by Roche with a detection range of 50–750,000 copies/ml. T-cell Subset (CD4/CD8), lymphocyte phenotypes were determined using 4-color flow cytometry, using monoclonal antibodies specific for lineage, activation, differentiation, and adhesion molecules. In addition, women reported on when they were first diagnosed with HIV.
Coping style was measured by a brief version of the COPE (21), a 28-item measure with subscales that measure a broad range of coping strategies. The current study examines active coping and avoidant coping (which combines Carver’s original denial and disengagement subscales). Cronbach’s alphas for active and avoidant coping in the current sample were .71 and .73, respectively.
Procedures and Analysis Approach
Unless otherwise indicated, all results presented below are for self-reported baseline data administered in person in interviewer format. The randomized trial was approved by an Institutional Review Board, and women were compensated $30 for baseline assessments. Data were entered into a web-based program developed by study staff and analyzed in STATA 10.0 (College Station, Texas 2007). Bivariate analyses were considered statistically significant if p-values from chi-square tests were <.05. Paired t-tests were conducted to compare means.
RESULTS
Of the 68 women in the current sample, 45.6% (n = 31) had custody of all of their minor children, and 54.4% (n = 37) had lost custody of at least one child. The 68 women had 143 minor children, of whom 44.8% were in their mother’s custody, and 42.0% lived with their mother. Among the children not in their mother’s custody (n = 79), 34.2% in state custody, 22.8% with the woman’s mother, 15.2% with an ex-partner of the woman, and the remaining 27.8% with other family members.
The mean age of women in the current sample was 39.6 years (SD = 6.7). The majority (80.9%) identified as non-Hispanic black, with 10.3% Hispanic, 7.4% non-Hispanic white, and 1.5% “other.” The mean annual family income was $8,524.64 (25th percentile $0, 75th percentile $14,400). Just under half (44.8%) reported having less than a high school education, 86.6% were unemployed, and 72.7% were on public assistance. At baseline the mean T-cell count in the sample was 483.91 (SD = 304.83), and log HIV viral load was 3.0 (SD = 1.39). The average number of years since the woman was diagnosed with HIV was 9.25 (SD = 4.87). Two women did not report when they were first diagnosed with HIV. All women had at least one lifetime DSM–IV substance use diagnosis: 91.2% had a diagnosis of cocaine dependence, 69.1% alcohol dependence, 39.7% cannabis dependence, 14.7% opioid dependence, 14.7% sedative dependence, 5.9% cocaine abuse, 10.3% alcohol abuse, 19.1% cannabis abuse, 5.9% opioid abuse, and 11.8% sedative abuse. Most (76.5%) were diagnosed with dependence on more than one substance.
The only demographic difference between the two groups is that a greater percentage of women without custody were unemployed (94.4%) compared to women with custody (77.4%) (p = .042). No statistically significant differences were found between the two groups related to HIV/AIDS indicators.
There were no statistically significant differences found regarding lifetime drug use, including the types of substances used, accumulative years of use, and the ASI drug use composite scale (Table 1). The custody group reported receiving more sessions of drug treatment in their lifetime (M = 5.21, SD = 9.54) compared to the non-custody group (M = 1.68, SD = 2.00) (p = .0318). The two groups did not differ on any of the mental health indicators except for history of trouble controlling violent behavior (p = .010). More women in the lost custody group had been incarcerated (p = .003) and arrested on drug charges (p = .002), which was the most common arrest offense among all of the women in the current sample and accounted for 56.1% of all arrests.
TABLE 1.
Selected characteristics of HIV+ mothers in substance abuse recovery by custody status
| Total N = 68 |
Has custody of ALL her children N = 31 |
Does NOT have custody of ≥ 1 child(ren) N = 37 |
p-value | |
|---|---|---|---|---|
| HIV-related characteristics | ||||
| CD4 T-cell count | 483.91 (304.83) | 555.97 (324.73) | 425.86 (278.91) | .0872 |
| Viral load (log) | 3.00 (1.39) | 3.10 (1.35) | 2.92 (1.43) | .6206 |
| Years since HIV diagnosis | 9.25 (4.87) | 9.60 (5.42) | 8.96 (4.43) | .6025 |
| Recent substance use | ||||
| No. of substances (abuse) | .59 (.88) | .65 (.84) | .54 (.93) | .6309 |
| No. of substances (dependence) | 2.35 (1.23) | 2.35 (1.25) | 2.35 (1.23) | .9908 |
| No. of diagnoses | 2.94 (1.24) | 3.00 (1.10) | 2.89 (1.37) | .7241 |
| Drug composite scale (ASI) | .07 (.08) | .05 (.05) | .08 (.10) | .0889 |
| Lifetime substance use | ||||
| Alcohol (ever) | 81.5 (53) | 83.3 (25) | 80.0 (28) | .730 |
| Alcohol (no. of years used) | 10.89 (9.93) | 11.53 (10.97) | 10.34 (9.08) | .6338 |
| Cocaine (ever) | 100.0 (67) | 100.0 (30) | 100.0 (37) | — |
| Cocaine (no. of years used) | 13.85 (7.41) | 14.27 (8.07) | 13.49 (6.89) | .6752 |
| Cannabis (ever) | 72.7 (48) | 70.0 (21) | 75.0 (27) | .650 |
| Cannabis (no. of years used) | 10.83 (11.03) | 10.87 (11.99) | 10.81 (10.34) | .9823 |
| ≥ 1substance/day (ever) | 82.1 (55) | 86.7 (26) | 78.4 (29) | .379 |
| ≥ 1substance/day (years) | 11.79 (9.51) | 13.63 (10.19) | 10.30 (8.78) | .1548 |
| Other (sedative, hypnotic, tranquilizer) (ever) | 22.7 (15) | 30.0 (9) | 16.7 (6) | .198 |
| Other (sedative, hypnotic, tranquilizer) (years) | 2.21 (6.63) | 2.27 (6.07) | 2.17 (7.14) | .9519 |
| Total years of substances used | 42.16 (34.78) | 43.6 (37.15) | 40.88 (33.07) | .7579 |
| Drug treatment (ever) | 74.2 (49) | 82.8 (24) | 67.6 (25) | .161 |
| Drug treatment (times) | 3.23 (6.67) | 5.21 (9.54) | 1.68 (2.00) | .0318* |
| Recent mental health | ||||
| Global severity index (BSI) | .78 (.71) | .72 (.70) | .83 (.72) | .5200 |
| Depression (SIGH-AD) | 4.99 (4.92) | 5.57 (5.28) | 4.51 (4.62) | .3873 |
| Lifetime mental health | ||||
| Anxiety symptoms | 74.6 (50) | 70.0 (21) | 78.4 (29) | .433 |
| Hallucination symptoms | 23.9 (16) | 13.3 (4) | 32.4 (12) | .068 |
| Problems with violent behavior | 59.1 (39) | 41.4 (12) | 73.0 (27) | .010* |
| Physical abuse | 42.4 (28) | 46.7 (14) | 38.9 (14) | .524 |
| Sexual abuse | 33.3 (22) | 26.7 (8) | 38.9 (14) | .294 |
| Incarcerated (ever) | 62.7 (42) | 43.3 (13) | 78.4 (29) | .003* |
| Incarcerated (mean months) | 8.03 (11.83) | 5.67 (9.43) | 9.95 (13.29) | .1423 |
p <.05, two-tailed.
Because the two groups had differences in lifetime drug treatment despite similar drug use patterns, we conducted post-hoc analyses on participation patterns in the randomized trial interventions and on coping styles. We hypothesized that the non-custody group would have lower rates of intervention participation and less active/more avoidant coping. Of the 59 women randomized into one of the two study interventions, SET and a health education and support group, overall 54.2% engaged in treatment (9 of the 68 women in our sample failed to attend the full baseline assessment and therefore were not randomized into the clinical trial). Treatment engagement was defined as attendance at two or more intervention sessions. The percentage of women who engaged into treatment was significantly different between the custody (76.9%) and non-custody (36.4%) groups, (p = .002). In addition, a t-test revealed that the difference of mean number of sessions was significantly different between the groups (p = .014), with the custody group having attended a mean of 4.85 sessions (SD = 3.57) and the lost custody group having attended a mean of 2.45 sessions (SD = 3.61). Avoidant coping was significantly higher in the lost-custody group (M = 9.09, SD = 3.31) compared to the custody group (M = 7.35, SD = 3.29) (p = .0495), but there was no significant difference in active coping (p = .1476).
DISCUSSION
This exploratory study found that roughly half of the mothers eligible for a clinical trial for HIV+ women in drug recovery did not have custody of all of their children, a prevalence of lost custody that is consistent with other research indicating that this population of dually-diagnosed mothers is at high risk for losing child custody. In comparing the two groups of mothers, we found that those who had lost custody were more likely to be unemployed and to have a history that included violent impulses and arrest on drug charges. The groups did not differ on recent or lifetime drug use but women who had lost custody attended less drug treatment in their lifetimes. Women who had lost custody had lower levels of engagement and participation in both family-based and health education support group interventions, and scored higher on avoidant coping.
Our finding that receiving drug treatment is associated with having child custody is consistent with previous research. Smith found that, among parents who had at least one child placed in substitute care by child protective services, the parents who completed drug treatment had an increased chance of family reunification (22). Grella, Hser, and Huang studied over 4,000 mothers entering substance abuse treatment and found that the mothers who had regained custody of their children had more extensive treatment history (23).
Our preliminary attempt to understand the mechanisms that drive this failure to access treatment suggests a link with avoidant coping style, a tendency to ignore or give up on attempting to deal with problems. There exists extensive literature on the challenges of and interventions for engaging adult substance abusers into treatment (24). Dakof and colleagues found that an Engaging Moms Program (EMP) was efficacious for improving drug treatment attendance rates among mothers of drug-exposed newborns (25). In EMP the therapist plays a highly active role in mobilizing the family to have the mother enter treatment. This approach could be useful for women with an avoidant coping style and could prevent mothers from losing child custody.
LIMITATIONS
This study has several limitations so results should be considered as strictly preliminary. First, the clinical trial was not designed to test these relationships. The small sample size limits generalizability of findings and our ability to test anything beyond simple relationships.
IMPLICATIONS FOR FUTURE RESEARCH
Given the prevalence of loss of child custody among HIV+ mothers in drug recovery and the serious sequelae that such disruptions can have on children and families, a better understanding of the factors and mechanisms associated with loss of child custody is warranted. Such information could inform interventions to prevent loss of child custody and to help reunite families, particularly strategies to improve outreach and treatment engagement for this population of dually-diagnosed mothers.
Footnotes
Declaration of Interest The authors report no conflict of interest. The authors alone are responsible for the content and writing of the article.
Contributor Information
Victoria B. Mitrani, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida, USA
Nomi S. Weiss-Laxer, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida, USA
Daniel J. Feaster, Center for Family Studies, Department of Epidemiology and Public Health, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
REFERENCES
- 1.Boyd-Franklin N, Steiner GL, Boland M. Children, Families, and HIVAIDS: Psychosocial and Therapeutic Issues. Guilford Press; New York, NY: 1995. [Google Scholar]
- 2.Pequegnat W, Szapocznik J. The role of families in preventing and adapting to HIV/AIDS: Issues and answers. In: Pequegnat W, Szapocznik J, editors. Working with Families in the Era of HIV/AIDS. Sage Publications; Thousand Oaks, California: 2002. pp. 3–26. [Google Scholar]
- 3.Owens S. African American women living with HIV/AIDS: Families as sources of support and of stress. Social Work. 2003;48(2):163–171. doi: 10.1093/sw/48.2.163. [DOI] [PubMed] [Google Scholar]
- 4.Bor R, Du Plessis P. The impact of HIV/AIDS on families: An overview of recent research. Families, Systems, and Health. 1997;15(4):413–427. [Google Scholar]
- 5.DeMatteo D, Wells LM, Goldie RS, King SM. The “family” context of HIV: A need for comprehensive health and social policies. AIDS Care. 2002;14(2):261–278. doi: 10.1080/09540120120076940. [DOI] [PubMed] [Google Scholar]
- 6.Boland MG, Czarniecki L, Haiken HJ. Coordinated care with children with HIV infection. In: Stuber ML, editor. Children and AIDS. American Psychiatric Association; Washington, DC: 1992. pp. 165–181. [Google Scholar]
- 7.Kotchick BA, Forehand R, Brody G, Armistead L, Morse E, Simon P, Clark L. The impact of maternal HIV infection on inner-city African American families. Journal of Family Psychology. 1997;11(4):447–461. [Google Scholar]
- 8.Reyland SA, McMahon T, Higgins-Delessandro A, Luthar SS. Inner-city children living with an HIV-seropositive mother: Parent–child relationships, perception of social support, and psychological disturbance. Journal of Child and Family Studies. 2002;11(3):313–329. [Google Scholar]
- 9.Cowgill BO, Beckett MK, Corona R, Elliott MN, Zhou AJ, Schuster MA. Children of HIV-infected parents: Custody status in a nationally representative sample. Pediatrics. 2007;120:e494–e503. doi: 10.1542/peds.2006-3319. [DOI] [PubMed] [Google Scholar]
- 10.Conners NA, Bradley RH, Mansell LW, Liu JY, Roberts TJ, Burgdorf K, Herrell JM. Children of mothers with serious substance abuse problems: An accumulation of risks. The American Journal of Drug and Alcohol Abuse. 2004;30(1):85–100. doi: 10.1081/ada-120029867. [DOI] [PubMed] [Google Scholar]
- 11.Barroso J, Sandelowski M. Substance abuse in HIV-positive women. Journal of the Association of Nurses in AIDS Care. 2004;15(5):48–59. doi: 10.1177/1055329004269086. [DOI] [PubMed] [Google Scholar]
- 12.Knowlton A, Buchanan A, Wissow L, Pilowsky DJ, Latkin C. Externalizing behaviors among children of HIV seropositive former and current drug users: Parent support network factors as social ecological risks. Journal of Urban Health. 2007;85(1):62–76. doi: 10.1007/s11524-007-9236-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Leonard NR, Gwadz MV, Cleland CM, Vekaria PC, Ferns B. Maternal substance use and HIV status: Adolescent risk and resilience. Journal of Adolescent. 2008;31:389–405. doi: 10.1016/j.adolescence.2007.07.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Mitrani VB, Szapocznik J, Robinson-Batista C. Structural ecosystems therapy with HIV-positive African American mothers. In: Pequegnat W, Szapocznik J, editors. Working with Families in the Era of HIV/AIDS. Sage Publications; Thousand Oaks, California: 2000. pp. 243–279. [Google Scholar]
- 15.Szapocznik J, Feaster DJ, Mitrani VB, Prado G, Smith L, Robinson-Batista C, Schwartz SJ, Mauer MH, Robbins MS. Structural ecosystems therapy for HIV-seropositive African American women: Effects on psychological distress, family hassles, and family support. Journal of Consulting and Clinical Psychology. 2004;72(2):288–303. doi: 10.1037/0022-006X.72.2.288. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Carpenter CC, Cooper DA, Fischl MA, Gatell JM, Gazzard BG, Hammer MD, Hirsch MS, Jacobsen DM, Katzenstein DA, Montaner JS, Richman DD, Saag MS, Schecter M, Schooley RT, Thompson MA, Vella S, Yeni PG, Volberding PA. Consensus statement: Antiretroviral therapy in adults: Updated recommendations on the international AIDS society—USA panel. Journal American Medical Association. 2000;283:381–391. doi: 10.1001/jama.283.3.381. [DOI] [PubMed] [Google Scholar]
- 17.WHO World Health Organization; Sydney, Australia: CIDI-Auto 2.1: Administrator’s Guide and Reference. 1997
- 18.McGahan P, Griffith J, Parente R, McLellan T. Addiction Severity Index Composite Scores Manual. Treatment Research Institute; Philadelphia, PA: 1986. [Google Scholar]
- 19.Derogatis LR. Brief Symptom Inventory: Administration Scoring and Procedures Manual. 3rd ed National Computer Systems; Minneapolis, MN: 1993. [Google Scholar]
- 20.Williams J. A structured interview guide for the Hamilton Depression Rating Scale. Archives of General Psychiatry. 1988;45:742–747. doi: 10.1001/archpsyc.1988.01800320058007. [DOI] [PubMed] [Google Scholar]
- 21.Carver CS. You want to measure coping but your protocol’s too long: Consider the Brief COPE. International Journal of Behavioral Medicine. 1997;4(1):92–100. doi: 10.1207/s15327558ijbm0401_6. [DOI] [PubMed] [Google Scholar]
- 22.Smith BD. How parental drug use and drug treatment compliance relate to family reunification. Child Welfare League of America. 2003;82(3):335–365. [PubMed] [Google Scholar]
- 23.Grella CE, Hser YI, Huang YC. Mothers in substance abuse treatment: Differences in characteristics based on involvement with child welfare services. Child Abuse and Neglect. 2006;30:55–73. doi: 10.1016/j.chiabu.2005.07.005. [DOI] [PubMed] [Google Scholar]
- 24.Stanton MD. Getting reluctant substance abusers to engage in treatment/self-help: A review of clinical outcomes and options. Journal of Marital and Family Therapy. 2004;30(2):165–182. doi: 10.1111/j.1752-0606.2004.tb01232.x. [DOI] [PubMed] [Google Scholar]
- 25.Dakof GA, Quille TJ, Tejeda MJ. Enrolling and retaining mothers of substance-exposed infants in drug abuse treatment. Journal of Consulting and Clinical Psychology. 2003;71(4):764–772. doi: 10.1037/0022-006x.71.4.764. [DOI] [PubMed] [Google Scholar]