Abstract
Families who enter the Child Welfare System (CWS) as a result of a caregiver’s substance use fare worse at every stage from investigation to removal to reunification (Marsh et. al 2007). Intervening with caregivers with Substance Use Disorders (SUDs) and their children poses unique challenges related to the structure and focus of the current CWS. Research demonstrates that caregivers with SUDs are at a greater risk for maladaptive parenting practices, including patterns of insecure attachment and difficulties with attunement and responsiveness (Suchman, 2006). Caregivers with SUDs have also often experienced early adversity and trauma. However, traditional addiction services generally offer limited opportunities to focus on parenting or trauma, and traditional parenting programs rarely address the special needs of parents with SUDs. This article details four innovative interventions that integrate trauma-informed addiction treatments with parenting for families involved in the child welfare system. Common mechanisms for change across programs are identified as critical components for intervention. This work suggests the need for a paradigm shift in how cases involving caregivers with substance use disorders are approached in the child welfare system.
Introduction
In the child welfare system (CWS), cases involving caregiver substance use disorders (SUDs) are among the most complex with poorer outcomes documented at every point in the process (Marsh, Smith, & Bruni, 2011). Intersecting structural, case, and treatment level factors contribute to why SUDs cases represent such a challenge for the system to manage and address (Bosk, Van Alst & Van Scoyoc, 2017). New approaches that offer innovative models which attend to the complexity of SUDs, particularly with regard to its impact on parenting and children’s socio-emotional development are needed for effective intervention and to improve case outcomes (Suchman, Mayes, Conti, Slade & Rounsaville, 2004; Suchman, Pajulo, Decoste &s Mayes, 2006). In this conceptual paper, we introduce readers to the importance of relationship-focused interventions in SUDs treatment, highlighting the evidence that supports a paradigm shift in how SUDs cases within child welfare are managed. We then identify four innovative treatment models, specifying the common mechanisms for change across them. Following this discussion, we present the development of each model, investigating the ways in which specific local conditions and constraints contributed to their emergence, design, and delivery. Taken together, these case studies provide templates for how relationship-focused interventions could be implemented within the child welfare system, offering new opportunities to keep families together during recovery and to improve CWS outcomes.
Theoretical Framework
The Complexity of SUDs Cases in the Child Welfare System
Not only are CWS cases involving caregiver SUDs among the most challenging, they are also among the most prevalent with 50–80% of families within the CWS impacted by SUDs in some way (Marsh et al., 2011). A helpful framework from which to understand the complexity of SUDs cases in the CWS is through an ecological-transactional model which highlights the bidirectional effects between individuals, their relationships, and their environments (Sameroff & MacKenzie, 2003). Moving beyond risk and protective factors, ecological-transactional theory identifies how children and adults both continually shape, and are shaped by, interactions with each other and the world around them. For example, negative early experiences for caregivers may create the conditions for substance use, impacting employment and socio-economic status. Caregivers’ stress related to their low socio-economic status may then contribute to mental health challenges which are associated with harsh or punitive parenting strategies, negatively affecting children’s socio-emotional development, leading to a hostile or distant parent-child relationship (MacKenzie, Kotch, Lee, Augberger, & Hutto, 2011a; MacKenzie, Kotch, & Lee, 2011b; MacKenzie, Nicklas, Brooks-Gunn, & Waldfogel, 2011c; Kim & Ciccheti 2010). In short, outcomes (such as the development of a SUDs or parenting impairment) do not emerge as the result of a single event but from dynamic processes that involve distal and proximal inputs. Without appropriate intervention, the interrelationship between SUDs, trauma, adverse childhood experiences, economic stress, mental health, parenting and child development set-up caregivers with SUDs and their children for continued involvement in the CWS and likely underlie why cases involving SUDs are associated with poorer outcomes. (Marsh et al., 2011).
Substance Use Disorder, Trauma, Neural Circuitry and Parenting
Among caregivers with SUDs co-occurring mental health disorders and trauma exposure are common. Research identifies very high rates of child maltreatment and trauma in individuals who are accessing addiction treatment services with estimates that 65% of clients have a history of child maltreatment (SAMSHA, 2013) and up to 90% of women have a trauma history (SAMSHA, 2010). In one study, among clients who reported a history of child maltreatment, 50% experienced sexual or physical assault in their early years (Brems, Johnson, Neal, & Freemon, 2004). The etiology of both substance use and mental health disorders have been clearly linked to adverse childhood experiences (ACES), with each adverse experience leading to a greater likelihood of negative outcomes in adulthood (Van Niel, Pachter, Wade, Felitti, & Stein, 2014). These negative outcomes can, and do, include the co-occurrence of SUDs and mental health disorders. The National Epidemiologic Survey on Alcohol and Related Conditions found that among people with a SUDs, 29.7% also met the clinical threshold for a mood disorder and 26.2% met the threshold for an anxiety disorder.
Caregivers early traumatic experiences, SUDs, and mental health disorders all have the potential to affect parenting, placing caregivers at risk for involvement in CWS. Trauma and mental health disorders broadly impact the caregiving system (also referred to as the attachment system), which is comprised of both mental representations (cognitive schemas about caregiving) and parenting behaviors (for an overview see: Sroufe, 2005). At a most basic level, caregivers whose early trauma stems from impairments in relationships with their own primary caregivers have few(er) positive mental representations to draw from when parenting. Mental representations matter because they provide the basis for interactions. Lack of positive mental representations or negative templates for caregiving can become translated in to hostile, harsh, or disengaged parent-child interactions, (Hesse & Main, 2006; Lieberman, 2004; Sokolowski, Hans, Bernstein, & Cox, 2007) which have larger implications for children’s relational development and security (Feldman, Dolberg, & Nadam, 2010; Huth-Bocks, Muzik, Beeghly, Earls, & Stacks, 2014).
Research on complex trauma demonstrates that early impairments in relationships are connected to diminished regulatory capacities across multiple domains (Van Der Kolk, 2017) such as affect management, distress tolerance, and impulse control. Caregivers ability to regulate their affect and sensitively respond to their children (particularly their very young children) is a primary mechanism by which children themselves develop their own capacities to regulate their emotional states (Beeghly, Fuertes, Liu, Delonis, & Tronick, 2011; Bernier, Carlson, & Whipple, 2010). As a group, caregivers with SUDs not only have difficulties regulating their emotions but are also more likely to engage in a range of maladaptive parenting strategies such as: responding to their children harshly (Kelley, Lawerence, Milletich, Hollis, & Henson, 2015; Slesnick, Feng, Brakenhoff, & Brigham, 2014), being less attuned to emotional cues (Minnes, Singer, Arendt, & Satayathum, 2005), maintaining inappropriate developmental expectations (Flykt et al., 2012), intrusiveness (Eiden, Stevens, Scheutze, & Dombkowski, 2006), overreactivity (Edwards, Homish, Eiden, Grohman, & Leonard, 2009), lack of warmth (Eiden, Colder, Edwards, & Leonard, 2009), lack of structure and flexibility (Moss, Lynch, Hardie, & Baron, 2002), and decreased involvement (Barnard & McKeganey, 2004). Each of these caregiving behaviors has been strongly connected to children’s socio-emotional development and later capacities for parenting. Young children whose needs are unpredictably met, not responded to, or responded to harshly may develop a sense of the world as an unsafe place and of the self as unworthy or incompetent (Raby, Roisman, Fraley, & Simpson, 2015). Further, children who cannot count on their caregiver for emotional or physical safety may form a template of relationships as disengaged, unpredictable or unsafe (Doyle & Cicchetti, 2017), which can be classified in terms of insecure attachment styles. Insecure attachments are connected to a range of internalizing and externalizing behaviors that impact children well into adulthood (Borelli et al., 2010) and are associated with having a caregiver with a SUD.
Developments in the neuroscience of addiction and parenting suggest a significant overlap in the neural circuitry involved with chronic drug use and parenting (Rutherford, Williams, Moy, Mayes, & Johns, 2011; Strathearn, 2011; Strathearn, Fonagy, Amico, & Montague, 2009). Chronic drug use appears to co-opt the same dopaminergic neural pathways recruited during caregiving, decreasing reward sensitivity, heightening stress activation, and potentially increasing vulnerability to relapse during caregiving activities. One consequence of this neural “hijacking” is that parenting may be experienced as more stressful and less rewarding to parents in addiction recovery as long as neural reward circuits remain altered.
Interactional Challenges
Theories for why SUDs develop in response to early adversity or trauma focus on the ways in which substance use can attenuate negative feelings or states (Rutherford, Potenza, & Mayes, 2013). The self-medication hypothesis (Khantzian, 1997) asserts that substance use is primarily a “a strategy to cope with stressors, to reduce tension,” and to decrease withdrawal and related distress (Chaplin & Sinha, 2013).1 There is significant evidence that both cumulative adversity and/or early relational impairments can impede the capacity to distinguish between or regulate feeling states, creating vulnerability for the development of a SUD. The ability to regulate stress and manage emotions is critical in parenting and new research suggests that parents with SUDs may both “find caregiving more stressful than non-addicted parents, and that the stress of caring for a child may increase [addicted parents] craving for substances” (Rutherford, Potenza,& Mayes, 2013, pg. 14). Therefore, vulnerabilities related to trauma histories converge in parenting and SUDs to create potential negative feedback loops.
In addition to the socio-emotional developmental consequences of poor quality parent-child interactions and parent-child relationships, children whose caregivers have a SUDs often experience poor outcomes across domains, which themselves affect parent-child interactions and parent-child relational quality. While the impact of prenatal exposure to substance (PSE) varies in relationship to timing and type of exposure; a range of cognitive, social, psychological and health problems have been associated with maternal use during pregnancy (Behnke & Smith, 2013). Children with PSE may be more challenging to care for due to the neurobiological effects of exposure and/or environmental inputs. Some research demonstrates that infants with PSE to cocaine exhibit increased negative affect, greater distancing and disengagement with parents and that their cues can be harder to distinguish (Tronick et al., 2005). However, other research indicates that more than PSE, family environmental inputs related to sub-optimal parenting including intrusiveness, low maternal sensitivity and emotional availability along with other maladaptive parenting strategies influence negative outcomes for substance-exposed infants (Salo & Flykt, 2013). Additionally, there may be an overall pattern of lower quality in parent-child interactions leading to compromised attachment relationships (Pajulo & Kalland, 2013). Whichever the case, the parents who may need greater support with caregiving are then also likely to have higher needs children, straining the processes by which secure relationships develop. As such, the substance-exposed mother and child are difficult regulatory partners for each other given the infant’s increased needs and the mother’s often decreased capacities to read her child’s signals (Pajulo, et al., 2008). The potential neurobiological, relational, and cognitive challenges for caregivers with SUDs and their children create unique and specialized needs for intervention.
These needs are compounded by the environmental adversity that caregivers with SUDs in CWS often face. Families with SUDs in the CWS report multiple service needs beyond assistance with achieving and maintaining sobriety and caregiving (Marsh et al., 2011). Difficulties associated with low socio-economic status such as obtaining employment, food security, housing, child care and transportation are frequently noted with 75.9% of mothers with a SUDs experiencing four service needs (Choi & Ryan, 2007). Recent work conducted by one of the authors found that the most common combination of risk factors for families with three or more risks in the New Jersey child welfare system were caregiver mental health issues, caregiver substance use, and domestic violence (Author, 2018). The environmental circumstances of caregivers with a SUDs often complicate the receipt of standard interventions through barriers related to child care, transportation, time off from work, and food or housing insecurity and which are also chronic stressors for both recovery and caregiving.
Current Child Welfare Approaches to SUDs
Despite the centrality of trauma and early relational impairments in the development of both SUDs and caregiving challenges, standard interventions for caregivers with a SUDs in CWS do not focus on addressing underlying trauma or mental health issues in caregivers or the impact of substance use on the parent-child relationship (Suchman, et. al., 2004; Suchman, et.al., 2006). Instead, common approaches to intervention focus on either SUDs specific treatment (such as detox and 30-day in-patient treatment) and psychoeducation or behavior based parent skills training (Ibid). SUD treatment is individually focused and rarely, if at all, includes attention to the child or parent-child relationship (Hanson, Saul, Vanderploeg, Painter, & Adnopoz, 2015; Suchman, Mayes, Conti, Slade, & Rounsaville, 2004). Additionally, traditional SUDs treatment is often not trauma-informed (Flanagan, Korte, Killeen, & Back, 2016) or adequately able to attend to co-occurring mental health disorders in treatment (Grella & Stein, 2006). Trauma-informed practices center on ensuring client choice, control, and relational safety which work to simultaneously address the psychological, neurobiological, and relational sequelae of trauma in all services and points of care (Kirst, Aery, Matheson, & Stergiopoulos, 2017). However, SUD treatment often employs strategies that focus on consequences and compliance which are not consistent with this approach and which may be experienced as re-traumatizing to clients. Further, these programs do not attend to the ways in which parenting itself can be a motivation for or a barrier to recovery (Paris, Sommer & Marron, 2018, Hanson et. al., 2015).
In two seminal articles, one of the authors outlines the ways in which behavioral management or parent skills training are likely to be ineffective for caregivers with substance use disorders (Suchman et. al. 2004, Suchman et. al., 2006). While behavioral management or parent skills programs focus on reducing conflict and changing behavior, they do not emphasize understanding the child’s experience or increasing parental attunement, reflectivity, and responsiveness, which are key mechanisms for improving the quality of the parent-child relationship (Pajulo et al., 2008; N. E. Suchman, Decoste, Rosenberger, & McMahon, 2012). In particular, parental reflective functioning, defined as the ability to understand the mental state of oneself and one’s child, has been shown to be a key factor in mediating the impact of substance use on the caregiving relationship (Alvarez-Monjaras, McMahon, & Suchman, 2019; Flykt et al., 2012). The mismatch between traditional approaches to SUDs in CWS and the need to address the ways in which parenting deficits stem from, and are further impacted by, addiction, trauma, and relational impairments necessitate new models for intervention. This is of particular importance in the child welfare context where caregiving impairments are by definition related to a caregiver’s SUDs.
Innovations to Intervention in SUDs with Child Welfare Involved Families
Four innovative interventions designed to address the intersection of parenting, SUDs, and trauma offer a template for a paradigm shift in child welfare. Developed at different points over the last 15 years, these interventions represent new opportunities for responding to cases that include parents with SUDs. Briefly, Project BRIGHT is a dyadic attachment-based intervention for mothers and young children (birth through five) informed by Child-Parent Psychotherapy offered in conjunction with a caregiver’s treatment for SUDs. It has been incorporated as a therapeutic enhancement in residential, medication assisted and outpatient substance use treatment and as a home-based intervention. The C.A.R.E. model integrates trauma-informed and parent-infant mental health treatment in a residential substance use disorder treatment program. Family-Based Recovery (FBR) is an in-home dyadic treatment intervention for caregivers and their children age zero to three. Mothering from the Inside Out (MIO) is a 12 week, mentalization-based individual therapy for mothers delivered in conjunction with outpatient addiction treatment.
While each intervention is distinct in structure and occurs in some different settings all models discussed here target three common mechanisms for change. These mechanisms are: (1) increasing caregiver reflective functioning; (2) increasing caregiver and child emotional regulation capacities and; (3) increasing the quality of parent-child relationships through strengthening caregiver responsiveness, sensitivity, and attunement. Each of these targets contribute not just to greater capacity to parent but also to maintaining sobriety. Parental reflective functioning (RF) is directly associated with emotion regulation which provides a process for managing overwhelming feeling states that occur both in parenting and in cravings for substances. Caregiver responsiveness, sensitivity, and warmth are empirically connected to children’s healthy growth and development and are essential factors in the parent-child relationship. Reducing conflict in this relationship decreases stress which, in turn, helps parents increase feelings of parenting confidence and maintain sobriety. Taken together, Project BRIGHT, C.A.R.E., FBR and MIO, represent a menu of complementary interventions that attend to the unique and complex needs of caregivers with SUDs and their children in novel ways. The chart below summarizes the interventions and their targets for change.
While each of these interventions have come to a similar understanding of the mechanisms that are critical in addressing caregiver SUDs and children’s experiences, they have all emerged from distinct processes of intervention development. As such, each intervention represents a different point on the science to service continuum, a model for clinical science aimed to produce both implementable and effective treatments (Onken, Carroll, Shoham, Cuthbert, & Riddle, 2014). The varied origins of these interventions point to the strength of different processes for intervention development and the need to equally privilege both applied and scientific strategies (Ibid). This next section discusses the local conditions and constraints by which each innovative model for SUDs treatment emerged, demonstrating the potential for adoption and adaptation in different contexts.
Case Studies: Four Models for Supporting Parenting in Caregivers with SUDs Project BRIGHT (Building Resilience through Intervention: Growing Healthier Together):
Program description and development.
The BRIGHT intervention (Building Resilience through Intervention: Growing Healthier Together) was developed as a response to the developmental and behavioral needs of young children (birth through five years old) and their parents who were receiving treatment for SUDs and Co-Occurring Disorders (CODs). The Institute for Health and Recovery (IHR) had long noted the consequences of traumatic stress experienced by these children in their work with families struggling with substance misuse since its launch in 1990. IHR has provided direct services, policy and program development, research, capacity building, technical assistance and training on issues related to SUDs/CODs including trauma, parenting, domestic violence, services specific to child welfare, and other topics. One particular role of IHR was coordinating all intakes to the eight Family Residential Treatment (FRT) programs in Massachusetts serving families with parental SUDs and CODs. Given their coordinator role along with providing technical assistance, senior IHR leaders knew the needs of young children were not being met. While the trauma-informed treatment focus in these settings had been established, the explicit needs of the young children who had experienced traumatic events that often came along with having a parent with an SUDs (e.g., in PSE, exposure to domestic violence, incarceration of caregivers), had not been addressed. BRIGHT was developed to meet those children’s needs within the context of parental SUDs treatment.
IHR, in collaboration with the Center for Early Relationship Support at Jewish Family and Children’s Service (JF&CS) in Waltham, MA, The Child Witness to Violence Project (CWVP) at Boston Medical Center and the Boston University School of Social Work (BUSSW) were successful in receiving funding from SAMHSA through the National Child Traumatic Stress Initiative to develop BRIGHT within the eight FRTs (2009–2012) and fill this service gap. The collaboration brought together individuals and organizations with a variety of expertise. JF&CS were regional infant mental health experts in offering relational interventions for the perinatal period, including home visitation and therapeutic interventions for mothers with postpartum mood disorders and their infants. CWVP was part of the Early Trauma Treatment Network and offered the evidence-based intervention, Child Parent Psychotherapy. BUSSW had clinical, research and evaluation expertise in substance misuse, therapeutic parenting and infant mental health interventions and trauma. Together, partners leveraged their different areas of knowledge to develop and offer an evidence-informed dyadic intervention for young children and their parents with SUDs that would ameliorate child symptoms of traumatic stress and parental mental health challenges, and support optimal parenting and recovery.
Given the strong evidence that traumatic experiences and PSE can compromise brain development and healthy attachment relationships, BRIGHT partners chose the evidence-based treatment Child Parent Psychotherapy (Lieberman & Van Horn, 2005; Lieberman, Van Horn, & Ippen, 2005) as the foundation of the intervention given its flexibility, dyadic nature and focus on trauma and attachment. Goals of CPP include supporting and improving child-parent relationships in order to reduce traumatic stress and behavioral symptoms, thus returning the child to a healthier developmental trajectory.
Although CPP was chosen as the best option upon which to base the BRIGHT intervention, it was not developed for parents with SUDs. In order to meet the needs of children and parents within the context of the FRTs, the principles of CPP were adopted to develop the intervention along with evidence from the substance use treatment field and best practices for vulnerable parents with young children (Suchman et. al., 2006; Sadler, Slade, De Dios-Kenn, Webb, D, Currieri-Ezepchick, J., & Mayes, 2005). Given its basis on CPP, BRIGHT is a strengths-based, trauma-focused, primarily dyadic therapeutic model, using play and relationship-focused activities to improve parent-child interactions and overall development. Clinicians promote developmental progress through play, physical contact, and language. Developmental guidance is offered to parents who are anxious to understand their child’s development. Clinicians encourage parents to wonder about the meaning of children’s feelings and behaviors and may offer possible explanations. All of this is accomplished within the context of an emotionally supportive relationship where concrete assistance for problems of daily living is also provided. As BRIGHT was specifically developed for parents with SUDs and their young children, the intervention works to balance dyadic treatment with the individual needs of an adult in recovery. Given its importance in early parenting, BRIGHT clinicians work with parents to recognize and manage strong emotions in themselves and their children. Additionally, the intervention specifically encourages parental reflective functioning (RF) as a mechanism for parents to attune to their child’s emotions and behaviors (Slade, 2005). The parent’s own history, including how they were parented, traumas experienced, and substance misuse, are also addressed in sessions particularly regarding their influence on the parenting process and maintenance of recovery. Reflective supervision, an essential aspect of an infant mental health intervention, is offered to all BRIGHT clinicians.
BRIGHT was developed specifically as a therapeutic parenting intervention to be offered as an enhancement to SUD treatment. The first SAMHSA grant (2009–2012) enabled clinicians to offer the intervention within the eight Massachusetts FRTs. BRIGHT was initially offered for the typical 6–8 months length of stay (ultimately an average of 14 weekly sessions of 1–1 ½ hours for the 66 participating dyads) to pregnant and postpartum women, along with those who had children through five years of age. Where a focus on parenting in the early recovery period might seem antithetical to some models of substance use treatment, BRIGHT offered the possibility that feeling better as a parent could improve motivation for treatment and affect a parent’s ability to maintain their recovery. Evaluation findings from this first project demonstrated the feasibility of offering a dyadic, attachment-based intervention within residential SUD treatment along with improvements in mental health and parenting capacities (Paris, et al., 2015). Additionally, this first project highlighted the challenge of offering an intervention that relied on a very different theory and practice base from the addictions field.
The second SAMHSA grant (2012–2016) offered BRIGHT within three outpatient opioid treatment programs (OTPs offering methadone treatment) in Massachusetts. The move to an outpatient setting necessitated a somewhat different stance for BRIGHT clinicians. Whereas staff in the FRTs were familiar with many of the needs of parents and children by virtue of being family-focused treatment settings, OTPs were rarely set-up to accommodate children, although many accompanied their parents for daily dosing. Department of Children and Families (DCF) played an important role with many parents in methadone treatment. Whereas, parents in the FRTs had to be either pregnant, living with their child or reunifying within one month in order to remain in the program, many parents in the OTPs did not have physical custody of their children. Given the generally dyadic nature of the BRIGHT intervention, clinicians sometimes conducted sessions in the context of a parent-child visit at the DCF office or in another location. As in CPP, BRIGHT also conducted individual sessions with a parent either when a child was not available or when clinically indicated. Balancing the in-vivo focus on the parent-child relationship with the needs of a mother newly in recovery remained a central tenet in the clinical work. Offering consultation and training to OTP staff varied by site, although overall the programs were very appreciative of having the BRIGHT intervention available for their clients (Paris, et al., 2018).
In the current and third SAMHSA grant (2016–2021), BRIGHT is offered within a community agency that provides a continuum of care for people affected by addiction in Southeastern Massachusetts, an area of the state greatly affected by the opioid epidemic. This organization maintains many programs including an OTP and residential treatment, along with outpatient services related to substance misuse. BRIGHT II was sited in their OTP and the organization was particularly interested in maintaining the dyadic and attachment focus that BRIGHT offered to parents with young children. The clinical work remains much the same, but parents’ involvement with DCF has increased given state and federal policies, necessitating further accommodations in the intervention. Most BRIGHT sessions maintain a dyadic focus with mothers who have custody or frequent visitation with their children. In addition, a new approach, Attachment, Regulation and Competency (ARC) Grow, has been added when working with individual parents who may not have access to their children or are not ready for dyadic sessions. ARC GROW, a 12-session intervention utilizing psychoeducation and skills practice focused on attunement and self-regulation, has not yet been tested for parents with SUDs, so similarly to CPP, the model is modified.
Strengths and limitations of staged approach.
Quantitative evaluation data from BRIGHT I and II point to the feasibility and acceptability of the model to improve parenting capacities and parental mental health within substance use treatment. Qualitative findings from participants in the program overwhelmingly support the unique nature of and need for this therapeutic parenting intervention. Additional qualitative findings from BRIGHT clinicians and staff at the various substance use treatment programs highlight the value added by offering parents a chance to participate in a therapeutic parenting program while in treatment for SUDs. Given these findings, the state department of public health has provided funding to maintain some of the services initiated with SAMHSA funding. Although three services grants were awarded since 2009 to conduct BRIGHT, as is common in many community settings, the intervention has never been rigorously tested through random assignment. Yet, a knowledge base was developed through practice and rigorous evaluation. Recently, the Health Resources and Services Administration funded a pragmatic randomized clinical trial to test a home-based version of BRIGHT beginning in pregnancy for women in opioid treatment (Paris, 2018). Evaluation findings derived from the three SAMHSA grants are being used to inform this clinical trial demonstrating the services to science approach to developing feasible community-based interventions. Future studies should also closely examine aspects of implementation in varied settings. As the evidence continues to build for this relationship-focused intervention, BRIGHT trainings will be implemented nationally to educate clinicians and assist child welfare workers in identifying the best programs and approaches for their clients with SUDs and young children.
Program takeaways:
BRIGHT has demonstrated the feasibility of enhancing SUDs treatment programs with an attachment-based trauma informed intervention for parents and their young children.
A flexible dyadic approach is important when offering BRIGHT, engaging the parent and child when available, and being mindful of the recovery needs of the parent.
Based on the literature regarding parents with SUDs, BRIGHT clinicians’ experiences and evaluation findings, therapeutic parenting interventions must have a specific focus on emotion regulation and reflective functioning in order to improve parenting capacities, the parent-child relationship and break inter-generational cycles of trauma and substance misuse.
As it is for all IMH interventions, reflective supervision is an essential ingredient in dyadic therapeutic interventions for parents with SUDs
The C.A.R.E. Model
Program description and development.
The Center for Great Expectation’s (CGE) Trauma C.A.R.E. model emerged from an eight-year process of adopting a trauma informed approach to treating substance use for pregnant and parenting women. In 2008, CGE’s Adult Residential Treatment Program was a traditional SUDs treatment program. Common to residential treatment in New Jersey, the program was abstinence-based, instituting a 30 day “black out” period and a rigid set of rules that provided a daily routine, promoted a singular focus on one’s recovery and limited contact with anyone outside of the program. Rule infractions typically led to a loss of privileges. Threats or acts of physical aggression resulted in an immediate discharge. On-going non-compliance with rules and the treatment expectations prompted an administrative discharge from the program. Considered a “mommy and me” residential program, children (age 0–5) were able to live with their mothers at CGE, attending an on-site child development center while their mothers participated in daily treatment. Women who gave birth while in treatment brought their newborns to CGE when discharged from the hospital. A Parenting Educator/Nurse met with each mother weekly to teach basic parenting skills. Despite the unique opportunity to have children co-located onsite, it became apparent that something needed to change. Too many women were unsuccessfully leaving treatment because of aggressive behaviors, non-compliance and/or relapse. Staff intolerance and reactivity to such behaviors fueled a punitive approach to treatment. The women often did well in the program until they became the primary caregiver for their child. For many women, this new responsibility was overwhelming, triggering emotional dysregulation and exposed attachment problems. Children were reunified and then removed again when the mother was unsuccessful in treatment, subsequently adding another trauma to both the mother and the child’s growing list of adverse experiences.
CGE’s program developed as the New Jersey child welfare system was undergoing comprehensive reform. The NJ Child Protection Substance Abuse Initiative was one such effort and assisted parents to access treatment. Funds were set aside for residential “mommy and me” programs, such as CGE, and others scattered throughout the state. But these “mommy and me: all offered the same traditional SUDs treatment with no integrated parent-child intervention that, based on consistent research, leads to poor outcomes even for those who managed to successfully complete treatment. In 2010, a Program Manager with knowledge and experience treating women with both trauma histories and substance use disorders joined CGE. With buy-in from CGE’s administrative team, the program began its slow transformation toward becoming trauma informed. Guided by SAMHSA’s principles of trauma informed care (Safety, Trustworthiness and Transparency, Peer Support, Collaboration and Mutuality, Empowerment, Voice and Choice,) all aspects of the program were critiqued through a trauma lens and intentional changes made to reflect this trauma informed approach. No longer did it clinically make sense to focus only on treating substance use; treatment needed to address trauma as well. Staff required training and support in order to integrate trauma and substance use treatment and provide effective, relational interventions in a non-judgmental, non-stigmatizing residential environment. The primary goal of the parenting program became strengthening and repairing the attachment relationship between a mother and her child. CGE adopted The Nurtured Heart Approach (NHA) shifting the agency culture toward a nurturing approach in both SUDs and parenting interventions.
Clinicians detected clinical changes in their clients that appeared to be connected to the trauma focused treatment they were receiving. They noted that client self-efficacy was improving, and trauma symptoms, anxiety, depression, and sleep disturbances were decreasing. This set the stage for the launch of an outcome study as part of a Category III National Child Traumatic Stress Network grant awarded to CGE in collaboration with Emily Bosk at Rutgers University School of Social Work in 2015 to implement Attachment, Regulation and Competency (ARC), a trauma intervention for children, adolescents and their caregivers. ARC provides the framework to create a trauma-informed relational treatment environment to support the mother’s recovery from SUDs and improve the mother/child attachment relationship.
The Trauma C.A.R.E. model provides a framework for clinical and milieu-oriented interventions. Four cornerstone concepts describe the model’s framework: Culture, Approach, Relationship and Empowerment. Two cultural norms define CGE’s culture: safety and nurture. Creating safety is not merely reducing environmental risk; it necessitates an understanding about what the human nervous system needs to feel safe, for both staff and clients. The NHA promotes nurture as a cultural norm. CGE staff are trained and supported to nurture the greatness in clients and each other. CGE is committed to a trauma informed approach: realizing the widespread impact of trauma, understanding the potential paths for recovery, integrating knowledge about trauma into the program and policies and seeking to actively resist re-traumatization. The C.A.R.E. Model promotes relationship-based care that has been sorely lacking in substance use treatment for caregivers, despite the theory and research supporting the connections between early attachment and well-being. Empowerment is a trauma informed concept that CGE has operationalized in practice. It is experienced in the shift from an authoritative to a relational treatment style, reducing the power differential between counselor and client. It involves an understanding of how traumatic experiences impact a woman’s ability to use her voice effectively and make good choices for herself and her child. Subsequently, treatment decisions are made collaboratively with the client, empowering ownership of their treatment plan and recovery goals.
Strengths and limitations of the applied approach.
The Trauma C.A.R.E. Model reflects the core principles of trauma informed care and operationalizes these into agency practices and policies that change how substance use treatment is delivered. Shifting agency culture has its challenges, particularly in SUDs environments where deeply ingrained beliefs about treatment exist. While the majority of CGE staff buy-in to our model, a few individuals continue to passively resist, and it becomes increasingly difficult to find the time and motivation to help them embrace the change. Addressing trauma and its connection to SUDs is more difficult than delivering traditional SUDs treatment and requires clinical expertise that demands higher salaries. Relationship-based work takes time, and caregivers who have lost custody of their children do not have time on their side, based on the American Safe Families Act strict timeline for reunification. The addiction treatment system is not designed to provide adequate time for recovery, let alone relational repair. Unfortunately, the relational work that is started at CGE is rarely continued by other treatment providers once the client and her child transition to a lower level of care. To counteract this, CGE developed an in-home treatment program modeled after Family-Based Recovery (also featured in this paper) providing relationship-based parenting interventions, substance use counseling and case management for up to 18-months post treatment.
Finally, as CGE begins to develop evidence for its approach and integrate measurement-based care, CGE has experienced resistance from clinicians to adopt this practice due to the additional paperwork and time it takes to do so. However, building evaluative measures into the intake and discharge processes has helped to normalize their use. And the provision of timely score report data to clinicians has built enthusiasm and motivation for gathering objective clinical data, which we believe will reflect the clinical observations of client symptom reduction.
As a grantee of the National Child Traumatic Stress Network, The Center for Great Expectations is currently partnered with two substance use programs in New Jersey who provide long term residential treatment to mothers and their children, to implement the ARC model into their treatment programs. The Trauma C.A.R.E. model will be made available to these programs as a next step in their development as trauma-informed organizations. Evaluation of the C.A.R.E. model continues in order to establish its efficacy as a promising practice.
Program takeaways:
Embedding evidence based/promising trauma interventions into substance use treatment environments is critical to successful recovery for caregivers. Data from Kaiser Permanente’s Adverse Childhood Experiences Study has clearly established a link between early childhood trauma and the risk for developing a substance use disorder. If treatment fails to address the underlying trauma, long term outcomes will continue to be poor.
Acknowledging the impact of secondary traumatic stress and promoting self-care among staff is an important component to the sustainability of trauma informed care. Agencies must be sensitive to the needs of their staff and provide opportunities for self-care during work hours. This includes the provision of individual supervision in order to monitor the level of secondary traumatic stress and offer recommendations for self-care outside of work hours.
Creating a model from applied clinical observation has led to observed reductions in clinical symptoms and represents a possible pathway for intervention development. The C.A.R.E. model organically developed out of the positive outcomes observed by applying trauma informed principles in a substance use treatment environment. This model continues to be enhanced based on the ongoing data that is collected regarding clinical outcomes for the caregiver, her child(ren) and their relationship.
Family-Based Recovery
Program description and development.
Family-Based Recovery (FBR) developed out of a convergence of interests between child protective services and treatment providers wanting to address the needs of families impacted by parental substance use. In 2005 the State of Connecticut (CT) Department of Children and Families (DCF) initiated an internal review and regional meetings to understand the extent to which parental substance use impacted families involved with Child Protective Services (CPS). The meetings identified the paucity of family-focused programs and collaboration across systems of care and prioritized letting children live with their parents who are in treatment. DCF was encouraged to develop community-based care for families; consider attachment theory in service design; and address families’ co-occurring problems and housing needs. Because no extant models met these criteria, DCF asked faculty at the Yale Child Study Center (YCSC) and Johns Hopkins University (JHU) to co-construct a model (Hanson et al, 2015) to fill the treatment void. DCF had prior experience working with both institutions. In 2004, DCF had developed an in-home model, Multisystemic Therapy-Building Stronger Families (MST-BSF), which treated parents with a SUDs whose child was a victim of physical abuse and/or neglect. The MST-BSF substance use treatment component is based on Reinforcement Based Treatment (RBT) (Tuten et al, 2012), an evidence-based model developed at Johns Hopkins University.
Concurrent to DCF’s needs analysis, the YCSC had developed a proposal to expand its promising practice treatment model, the Coordinated Intervention for Women and Infants (CIWI) program. CIWI was an intensive in-home clinical service for women with a history of substance use who were pregnant or had an infant under the age of 12 months. CIWI provided individual, attachment-focused therapy to increase awareness of the needs of the infant, the goal being more developmentally appropriate maternal responses with increased positive parent-child interaction.
The model developers of CIWI and MST-BSF met in July 2006 to assess if the treatment approaches were compatible. It was quickly determined that both models placed a high value on the client’s experience of treatment and that taking components from each would have a synergistic effect, potentially transforming how families in CT struggling with SUDs would receive treatment. Three model designs were considered: 1) generalist: one clinician delivering both the substance use treatment and dyadic attachment work components; 2) integrated team: two clinicians, each delivering one component; and 3) clinic-based substance use treatment and in-home dyadic attachment work. The second design was selected to minimize drift in model fidelity and maximize support to clinician and family. Model developers also had to agree on sequencing of treatment component and service intensity. One proposal was that the initial focus of treatment would be parental substance use. Once a parent achieved sobriety and the family was stabilized, parent-child dyadic therapy would start. However, it was agreed that both components needed to be initiated concurrently as the parent-child dyad could not wait. Opinions on weekly clinical dosage ranged from seven and a half to a minimum of three hours. Three hours was selected due to caseload requirements to ensure the model was fiscally reasonable.
The basic premise of FBR is that the satisfaction of bonding with a young child and parenting competently reinforce abstinence, while recovery reinforces the ability to competently parent. The clinical approach is based on attachment theory and insight-oriented psychotherapy that empowers clients. The treatment team will hopefully become a “secure base” for parents so they can more readily be the same for their children. Respect, non-confrontation, patience, tolerance of rejection, and a willingness to allow the client to determine the pace and focus of sessions guides treatment. Active listening and thoughtful use of language is stressed to foster trust and the sense of feeling heard and understood. The parent-child sessions encourage reflection on how parents own early childhood experiences impact relationships and parenting now. Focus on moments of connection provides opportunities for the parent to see the child’s emotional and developmental needs and express their hopes and dreams for them. The substance use sessions are guided by the RBT tools that focus on understanding the positive and adverse outcomes of substance use, co-constructing goals to replace the function of the substance use, and identifying positive reinforcers to change, first and foremost, parenting a child. While the clinical work is divided between team members, parenting and recovery are interwoven into each component.
DCF funded six FBR teams, and the first case was opened in January 2007. The model development team remained intact for the first l years of the project to modify tools with lessons learned from the clinical teams, write a manual of policies and procedures, and provide weekly consultation to sites. After that, YCSC FBR Services assumed sole responsibility for model development, implementation, consultation, dissemination and replication. FBR Services has instituted a variety of mechanisms to strengthen model fidelity, increase staff’s understanding of infant mental health, and attend to the collaboration between FBR teams and DCF staff. FBR site coordinators meet monthly to discuss model implementation, staffing, relationship with DCF, and model updates. Consultants conduct site visits (parent-child quarterly, substance use annually) which involve a home visit with each clinician to provide support and feedback and a team training. An annual credentialing report evaluates sites’ implementation of the FBR model. A critical component of the intervention has been continued collaboration between DCF and FBR. Since 2007, FBR Services Director and DCF FBR contract manager have met with sites and area offices on an annual and ad hoc basis to discuss communication, collaboration, strengths and areas for growth, and to develop ways to strengthen the FBR-DCF partnership.
In 2011, FBR Services, with the backing of DCF, applied for and received a SAMHSA Service to Science Initiative grant. The award provided FBR Services with technical assistance to better define the FBR model and identify measures to fill the gaps evident in an evaluation plan. The Service to Science consultants assisted FBR Services in strengthening the Logic Model to accurately capture what FBR does and what difference it makes, detailing treatment specifics and adding expected long-term outcomes. The treatment manual developed highlights the mechanisms for change that FBR targets (see chart above).
Chart 1.
Model descriptions.
Consequently, the Center for the Application of Prevention Technologies (CAPT) awarded FBR Services a subcontract in 2013 to increase evaluation capacity, allowing FBR Services to field-test data collection instruments in three sites and develop a system for data tracking and analysis. The clinical data from parent-child measures and an Adherence Measure proved useful in understanding what FBR does and how sites do the work. The second goal for the CAPT grant was to assist FBR Services in developing a rigorous prospective research design. A research design was developed that would compare FBR to a clinic-based substance use treatment program; however, it was not implemented due to an inability to locate a community partner willing to participate. During the CAPT, DCF expanded funding from six to ten teams. FBR teams provide services to families in urban, suburban and rural settings throughout CT. In addition, DCF increased financial support to FBR Services to allow staff the time to expand the statewide network and focus on moving FBR from a promising practice to an evidence-based treatment program.
In 2015, FBR Services was selected by DCF and Social Finance, LLC, to participate in the development of a social impact bond project in CT. The CT Family Stability Project (FSP) funds two new FBR teams and four teams that are piloting an adaptation of the FBR model to treat families with an index child three to six years of age. The project will serve approximately 500 families over four and a half years and be evaluated via a randomized controlled trial. Outcomes will be determined based on reduction in parental substance use, out-of-home placements, and re-referrals to DCF and successful FBR enrollment. The FSP project has allowed FBR Services to participate in the first rigorous evaluation of the FBR models.
Strengths and limitations of the private-public development approach.
The FBR model development and implementation approach has strengths and limitations. This public-private endeavor allowed treatment providers an opportunity to develop a model to fill a service void and shift providers’ and CPS staff’s approach to working with families impacted by parental substance use. Collaboration between treatment model developers brought together areas of expertise and leveraged the motivation to parent as a reinforcement for change. One new challenge is that DCF staff are now familiar with and champions of the FBR program and have been reluctant to have families randomized into other treatment models. In addition, DCF decisions impact FBR treatment planning and outcomes and on a programmatic level, DCF weighs in on FBR model policies and procedures. Boundaries can become blurred at all levels of the partnership, requiring constant attention to the relationship and a new model for collaboration between interventionists and the child welfare system (Hanson, et. al. 2019).
Program takeaways:
The opportunity to parent can motivate mothers and fathers to enter substance use recovery
Public-private partnerships work to advance understanding that children can safely remain with parents with SUDs when provided appropriate clinical support
Two different treatment models can bring the strongest components to the table and be adapted to create a new model
Treatment providers need to be receptive to modifications to strengthen the model
All need to think outside the box when treating clients and securing financial support for interventions that address complex issues.
Mothering from the Inside Out
Program Description and Development.
Mothering from the Inside Out (MIO) was originally developed to address the absence of evidence-based interventions available for mothers diagnosed with substance abuse disorders. At the time of MIO’s inception, most evidenced-based parenting interventions were designed for parents who were struggling to care for children with challenging behaviors. Consequently, population-based parenting interventions were failing the needs of parents with significant mental illness and substance use disorders (see Suchman, Mayes, Conti, Slade, & Rounsaville, 2004; Suchman, Pajulo, DeCoste, & Mayes, 2006). MIO was developed in response to the dearth of effective interventions for parents whose mental illness and/or substance use were having significant impact on their capacities to care for their young children. MIO was conceived to address the neural reward circuitry changes associated with chronic substance use (e.g., Volkow, Fowler, & Wang, 2003; Kim, Iyengar, Mayes, Potenza, at al., 2017). Specifically, MIO was designed to address the psychosocial deficits that parents often experience in early addiction recovery (e.g., emotional dysregulation, heightened emotional distress, impulsivity, and absence of neural reward during social engagement). By targeting parental reflective functioning, the capacity to recognize, make sense of, and regulate emotional distress during stressful parenting interactions (including the parent’s own distress and the child’s activated attachment needs), we hypothesized that MIO would help mothers regulate their own emotional distress that might otherwise trigger drug cravings, emotional withdrawal or excessive control during interactions with children in their care.
Stage I Trial.
Over the course of 14 years, with funding from the National Institutes of Health, MIO was developed and evaluated in three randomized clinical trials. These trials followed a stage model of behavioral therapies research (see Rounsaville, Carroll, & Onken, 2001). In Stage I we finalized the intervention manual and assessment protocol and tested MIO’s preliminary efficacy for improving primary- (e.g., maternal RF) and secondary-targeted (e.g., mother-child interactions) in a randomized trial (Suchman, DeCoste, McMahon, Rounsaville, & Mayes, 2011). Prior to the Stage I trial, we had developed a conceptual model and piloted a group version of MIO (initially named Emotionally-Responsive Parenting) testing its preliminary efficacy for improving maternal RF. Although MIO demonstrated preliminary efficacy (see Suchman et al., 2004), our clinical observations of mothers’ and children’s needs for intensive case management and psychosocial support helped us realize the group format limited our capacity to form a strong working alliance or understand each mother’s unique circumstances and psychosocial strengths and vulnerabilities. During the Stage I trial, we therefore modified MIO as an individual intervention that included a comprehensive pre-intervention assessment, intensive case management, and 12 individually-tailored therapy sessions. In order to retain flexibility in tailoring MIO to individual participants, the treatment manual was written to provide guidance about the treatment process rather than its content. This approach allowed us to maintain treatment integrity (internal validity) while avoiding intervention rigidity (increasing generalizability). Early in the Stage I investigation, ample flexibility allowed us to modify the intervention approach and assessment protocol to find the “best fit” for the treatment population. This flexibility allowed the treatment and assessment approach to evolve organically based on the experience and feedback of participants and therapists. Later in the Stage I investigation, when the first efficacy trial was conducted, the randomized trial design and finite funding timeframe introduced a number of constraints to the intervention development: Flexibility of content notwithstanding, the pre-treatment assessments, participant eligibility criteria, randomized treatment assignment, and treatment format, frequency, and duration, and treatment approach all required consistency (and inflexibility) in order to maintain the study design’s integrity. At the conclusion of the Stage 1 trial, we found support for the proposed treatment model: therapist fidelity to promoting mentalizing in the session (even after controlling for therapist efforts to foster therapeutic alliance) predicted improvement in maternal RF which, in turn, predicted improvement in the mother-child relationship (even after controlling for improvement in substance misuse (Suchman, N., Decoste, C., Rosenberger, P., & McMahon, T.J, 2012). Interestingly, when we examined self-focused vs. child-focused mentalizing, it was self-focused mentalizing (i.e., the mother’s efforts to make sense of her own strong, negative emotions when she was stressed about parenting) that was associated with the quality of her caregiving behavior (Suchman, N., DeCoste, C., Leigh, D., Borelli, J., 2010).
Stage II Trial.
In Stage II we tested MIO’s efficacy and proposed mechanisms of change in a formal, sufficiently powered (large enough sample to detect significant effects) randomized trial in a “controlled” setting with research therapists (Suchman, DeCoste, McMahon, Dalton, Mayes, & Borelli, 2017). Because MIO (called the Mothers and Toddlers Program during the trial) demonstrated efficacy for improving maternal reflective functioning and mother-child interactions at the end of treatment that were sustained at the 6-week follow up, we didn’t consider changes to the intervention protocol necessary (see (N. Suchman, DeCoste, Castiglioni, Legow, & Mayes, 2008; N. E. Suchman et al., 2010; N. E. Suchman, Decoste, McMahon, Rounsaville, & Mayes, 2011). However, we made several changes to the research protocol including doubling the length of the follow up period (from 6 to 12 weeks), adding a one year follow up assessment visit, and adding an assessment of child attachment security. Both of these additions were considered essential for further testing the durability of MIO. We also expanded the eligibility criteria to include mothers of children up to 5 years of age (the previous upper limit was 3 years of age). Once the Stage II trial began, though, consistency of intervention and assessment approach was required to preserve the integrity of the research design. Evidence was again found for the proposed mechanisms of change: this time showing that therapist fidelity to the mentalizing component predicted improvement in maternal RF, which in turn predicted improvement in the mother-child relationship, which in turn predicted improvement in child attachment classification. Moreover, improvement in attachment classification was found for mothers with the most severe addiction histories (e.g., mothers with earlier initiation of substance use and with family histories of addiction)(Suchman et al., 2017), suggesting that MIO was especially beneficial to mothers with the most chronic addiction histories.
Stage III Trial.
In the Stage III trial, we first tested a training protocol with community counselors (Suchman, Borelli, DeCoste, in review) and are currently testing MIO’s efficacy a in a community-based randomized trial. At the completion of the Stage II trial, we again found that MIO demonstrated efficacy for improving maternal RF at the end of treatment and mother-child interaction quality at the end of the 13 week and 1 year follow up periods (N. E. Suchman et al., 2017). The treatment protocol was therefore not adjusted. However, improvement in attachment classification was not found at the end of treatment. Because improvement in other mother-child interaction indices seemed to involve a period of consolidation, we decided to assess attachment classification after the follow up period in the Stage III trial. We also learned anecdotally that some participants may have been reluctant to report their substance use rates on the self-reported timeline follow-back. We therefore developed a new self-report measure of risk for relapse (e.g., reports of cravings, illicit drug procurement, and activation of support systems) and improved the confidential nature of reporting (i.e., participants completed a questionnaire on a tablet that was submitted to an online database without review by study personnel). Finally, although retention rates in both trials were good (between 70 and 80% across both treatment arms in both trials), attrition was highest during the pre-treatment assessment, suggesting that assessment burden might be causing attrition. To promote retention in the Stage III trial, during which MIO would be delivered by addiction counselors in a community-based treatment setting, we shortened the assessment phase from four visits in four weeks to two visits in two weeks. Although this change may have compromised the data availability, it seemed like a reasonable trade-off for scaling up an efficacious intervention that would be feasible and acceptable in real world settings. To date, findings from the Stage III trial have shown the feasibility and efficacy of training addiction counselors in community-based settings to improve their own mentalizing capacities and deliver mentalization-based treatments with sustained fidelity (Suchman, N.E. Borelli, J.L, DeCoste, C.L., Under Review).
Strengths and limitations of the clinical trials approach.
The Staged model of intervention development has many strengths. It provided a useful progression for moving from intervention conception to real world delivery while systematically collecting data to monitor progress in terms of feasibility, treatment integrity, treatment outcomes, and treatment mechanisms. It allowed for the comparison of treatment mechanisms and outcomes across trials. It provided invaluable feedback to clinicians and researchers by operationalizing our assumptions and predictions about how a complex treatment works and allowing us to compare and combine data across trials. The randomized trial design assured certainty that treatment effects were due to the one manipulated factor – intervention assignment – while holding all other factors constant. The flexibility during Stage I allowed for the treatment to be developed, piloted and modified before committing to a specific approach. The flexibility between trials to make changes to the treatment and research protocol allowed for adaptation to unanticipated findings. Throughout the staged investigations, data served as a “third eye” for clinicians and researchers alike that monitored treatment progress objectively and, on more than one occasion, corrected our beliefs and assumptions about the treatment process. For example, through rigorously monitoring treatment fidelity, we learned that clinicians in both treatment arms were required to devote considerable time to fostering and maintaining the therapeutic alliance and addressing the mothers’ own deficits in self-care. At the same time, findings about mechanisms of change indicated to us that treatment alliance wasn’t sufficient for bringing about change in maternal RF (see Suchman, DeCoste, Rosenberger, & McMahon, 2012; Suchman, DeCoste, Borelli, & McMahon, 2018). This feedback helped us to understand the true and essential nature of MIO – the necessity of actively caring for the mothers so that they, in turn, could care for their children while also targeting RF. Without this third eye, we would have been somewhat blinded to the treatment process and how it worked.
Adherence to research protocols and inherent time constraints have inevitable drawbacks for providing treatment to a high-risk population, the greatest of which was limited flexibility. Once the clinical trials were under way, we did not have the flexibility to adapt the intervention in ways we might have wanted to in a normal clinical setting. For example, we did not have the liberty to increase the duration or frequency, include additional family members (e.g., fathers, other children, or grandparents). Nor did we have the liberty to change the intervention venue (e.g., make home visits, or meet in the community). We didn’t have the freedom to alter the intervention to include a dyadic intervention component. These limitations notwithstanding, our research design did include intensive case management and we did have the liberty to refer mothers and children throughout the study to additional services. Because our treatment was designed as an adjunct to addiction treatment, we were not required to restrict eligibility to mothers and children receiving no other services, as is often typical in randomized clinical trials. Instead, the services mothers and children received were carefully documented every week and taken into account in the outcome analyses.
Now that MIO has demonstrated efficacy under conditions of high internal validity (where clinicians in both treatment arms were trained by investigators to deliver assigned interventions with sustained fidelity), we are planning to test MIO under conditions of high external validity, where responsibility for clinical training and supervision are transferred to community providers. We are also planning to study organizational characteristics of outpatient addiction treatment programs to identify facilitators and barriers to MIO’s adoption. Strategies for addressing barriers and promoting facilitators can then be tested in a formal implementation trial.
In summary, the science-to-service model that we engaged in for 14 years allowed us to distill the essential efficacious ingredients of MIO such that it can now be disseminated with confidence that it can be effective for this high-risk treatment population. At the same time, it can be further evaluated in implementation trials for its effectiveness in different natural settings and cultures. Although it has taken time to proceed through the evaluation pipeline and its public health benefit to the treatment population is only now becoming evident, we believe that the careful and systematic evaluation on the front end will have tremendous public health benefits in the long run. With the opioid crisis at hand, MIO is now well poised to effectively assist families in recovery and be scaled up across states.
Program Take-Aways:
For mothers in addiction treatment, fostering the mother’s capacity to make sense of her own strong emotions that may be triggered in the parenting role may be the most important component of parenting interventions because it frees up psychological room for the mother to recognize and then respond a child’s emotional cues (see Suchman, DeCoste, Leigh, & Borelli, 2010).
Therapeutic alliance alone is not sufficient for promoting change in a mother’s capacity to care for her child. The therapist’s efforts to foster the mother’s RF is essential to bringing about change in the mother-child relationship (see Suchman, DeCoste, Rosenberger, & McMahon, 2012; Suchman, DeCoste, Borelli, & McMahon, 2018..
Addiction counselors can be instructed in mentalization-based treatment and can improve their own mentalizing capacities with the aid of ongoing reflective supervision. They are often superb at building the therapeutic alliance because they understand the science and treatment of addiction. They also have the unique capacity to address parenting and addiction within a single session (See Suchman, Borelli, & DeCoste, 2018).
Discussion
Although each model presented here originated in different ways in different contexts, all interventions responded organically to a need to provide more appropriate services to caregivers with SUDs often in the child welfare system and to address these needs in the context of recovery. Taken together, these case studies represent a new paradigm for SUDs treatment within the child welfare system and offer a complete set of interventions—from integrated residential treatment, to in-home addiction and dyadic services, to outpatient dyadic treatment and outpatient individual, adult focused treatment-- in which to offer services to families. Whatever their setting, length, or focus these innovative interventions all target the same key mechanisms for change: parental reflective functioning, emotion regulation, and the quality of the parent-child relationship, highlighting the need to pay attention to these processes when working with caregivers struggling with a SUDs. More broadly, these interventions also seek to help caregivers understand how their past experiences shape their substance use and their parenting as well as connect parenting stresses to triggers for use. The similarity in these programs’ approach alongside their continuity of targets for change suggest that each model is adaptable to different treatment settings and likely to work in multiple iterations.
The devastating and expanding reach of the opioid epidemic creates new urgency for innovative services for families impacted by Substance Use Disorder. For child welfare systems considering how to most effectively intervene, these innovative models offer important frameworks for practice. In particular, they emphasize the ways in which inattention to the parent-child relationship is likely to undermine efforts for addressing the ways in which SUDs impacts, and in the case of child welfare, impairs parenting, thereby setting up children and families for failure. By targeting the parent-child relationship, child, and caregiver outcomes, these models act both as preventative interventions for children and as primary interventions for parents.
As a group, these models could be adopted simultaneously or independently within the CWS. Likely, CWS that offer a range of services for caregivers with SUDs and the parenting relationship will best attend to the range of complex needs of families. It may be that some clients will respond best to individually focused treatment, as MIO provides, while others will find a better fit with in-home services like FBR that offer the ability to address both addiction and parenting in an intensive but non-residential setting. Extending client choices is a key tenet of trauma-informed care and therefore, providing different service options would be most consistent with this principle.
From a systems perspective, offering multiple kinds of family-focused treatment for caregivers with SUDs also likely would create the internal capacity to shift organizational approaches to caregivers with SUDs. While the models have all been developed and implemented in the northeast both FBR and MIO have been deployed in rural settings in Connecticut and South Africa respectively, indicating that these models will likely be feasible and adaptable across the full range of geographic settings. Each model described collaboration with their state’s Department of Children and Family Services as key to their ability to deliver treatment. Because the practices being implemented by Project BRIGHT, C.A.R.E., FBR, and MIO represents such a departure from traditional approaches to SUDs in child welfare, new normative understandings of what is safe for a child whose caregiver has a SUD are required. Traditionally, the presence of several positive toxicology screens or in the case of psychoactive substance, a single positive screen, warrants removal of a child from their home. For programs to be successful, DCF agencies likely need to have a greater tolerance for risk to enable caregivers to remain with their children while they are also still actively working toward recovery. In most of the models described, coordinated, regular, dialogue and collaboration between developers and the child welfare system is the key organizational mechanism for changing how these cases are typically handled. Organizations or communities considering implementing these interventions will need to first establish working relationships with their respective child welfare agencies as a precondition to adoption. The amount of collaboration required between the CWS, clinical providers, families, and traditional substance use services (such as outpatient treatment providers or medication assisted treatment centers in the case of MIO and Project BRIGHT) means that these interventions cannot just be added in to current treatments but instead require reflective work and specific attention to relationships among systems and providers to be successful. The capacity to provide reflective supervision should be part of the planning process for child welfare agencies considering the feasibility of adopting these models.
These four models also offer some of the first examples of a set of interventions emerging within the staged framework of intervention development outlined by Onken and colleagues (2014) which emphasizes both the applied and scientific stages of model creation. In this new framework, Onken et. al. outline six stages: Stage 0 (Basic Research), Stage 1 (Intervention Generation/Refinement), Stage II (Efficacy-Research Clinics), Stage III (Efficacy-Community Clinics), Stage IV (Effectiveness), Stage V (Implementation & Dissemination) for intervention development (Onken et al., 2014)). Unlike other science to service models where intervention development occurs within a set linear procedure that progresses from bench or research science to implementation, within this model stages are interchangeable and may happen in any order. This conceptualization of clinical science makes clear that “intervention development processes are incomplete until an intervention is optimally efficacious and implementable with fidelity by practitioners in the community” (Onken et. al. pg. 22). Thus, intervention development should be a dynamic and iterative process with multiple paths for creation and refinement. Case studies of the C.A.R.E. model, FBR, Project BRIGHT, and MIO support this new conceptualization. Project BRIGHT, C.A.R.E., FBR, and MIO are currently located on a distinct point in the science to service continuum and each has moved through the stages of intervention development in different orders. Despite originating at distinct stages, these interventions have come to identify and emphasize the same underlying mechanisms for change. Likely, this speaks to the strength of multi-directional model development where interventions developed in research settings are able to distill the efficacious components of change, which then influences the development of interventions emerging and responding to community calls for new models in real time. In this case, MIO and its developers have been a leader in the field, creating a wide body of knowledge and research from which FBR, Project BRIGHT, and C.A.R.E have drawn on and incorporated. Professional relationships between the developers of MIO, Project BRIGHT, FBR and C.A.R.E has meant that the field of treating caregivers with SUDs has emerged in an interdependent manner, reflecting the core relationship-based tenets on which the interventions are based.
Finally, the freedom to create interventions directly within the community means that many issues related to fidelity have been part of model development and refinement from their inception, rather than requiring developers to reverse engineer solutions for interventions that are efficacious in the research setting but turn out to be unrealistic to deliver in the community. For example, both FBR and Project BRIGHT have worked extensively with providers to refine the models as they have deployed them. Processes described here by developers also focus on real world issues not commonly thought about during bench science development such as financing and processes for scaling up and adapting interventions. Different financial mechanisms (e.g. federal research funding, federal direct service funding, state intervention development, and public-private partnerships) have both facilitated and constrained the ability of each model to move between stages. The case studies highlight that funding processes often dictate where on the science to service continuum an intervention is able to begin and when it may move to others. The impact and structure of financing on intervention development represents an understudied area of innovation in children and youth services.
The different location of each model on the staged framework for intervention means that next steps for dissemination and scaling of interventions look different for each model. However, the staged framework for intervention offers opportunities for each program to be disseminated from where they currently are situated.
Conclusion
Project BRIGHT, C.A.R.E, FBR, and MIO represent innovative models for intervention for caregivers with SUDs that reflect current research on the needs of this population. Taken together, each model presents options for creating the full continuum of care for integrated intervention for treating SUDs in the context of parenting from residential to in-home to dyadic outpatient and individual outpatient treatment. While different levels of evidence of efficacy accompany each model, it is significant that the targets for change are largely the same, even when the diversity of model structures are taken in to account. This points to a consensus in the field about what mechanisms are likely critical in interventions with caregivers with SUDs. These case studies provide support for a new staged framework for intervention which emphasizes the applicability and the efficacy of interventions equally. Such a model allows for an iterative and relational approach as evidence and experience from one model influence the development of another. The science is clear: interventions for caregivers with SUDs in the child welfare system require a focus on the ways in which this disorder is mediated and moderated by parenting. C.A.R.E, FBR, Project BRIGHT and MIO represent a paradigm shift for how interventions can be delivered that reflects the unique needs of caregivers and their children within the child welfare system.
The conceptually similar but logistically varied innovation of providing relationship-based care to mothers and young children affected by substance use is an innovation that might prove to be helpful in addressing the social problem of left behind children in rural China. Many of the Chinese contributors to this special issue describe innovations designed to address this significant social problem. Based on what we know about how separating children from their primary caregivers affects the attachment system, interventions targeting left behind children might be more effective if they focus on mitigating the traumatic impact of absent caregivers on the children and supporting healthy attachments with those left to care for them. As with the programs discussed above that recognize the common needs for parents with SUDs and their young children, interventions for left behind children could incorporate a focus on building attachments but vary in their delivery, depending on age and circumstance. This could be useful when thinking about Guan and Deng’s paper The Whole Community Intervention for Left-Behind Children in Rural China that evaluates the ‘Children Companion Mothers Program’ (CCMP) implemented in 20 rural towns in China. They indicate a lack of professional social workers in rural China and recommend that both para-professional and professional social service workers working with CCMP be provided with more training that promotes the well-being of left behind children and their families. Training in attachment focused care could potentially be provided utilizing the low-cost ‘remote’ training and coaching as evaluated by Walker and Baird in the article Using “Remote Training and Coaching to Increase Providers’ Skills for Working Effectively with Older Youth and Young Adults with Serious Mental Conditions. In in hard to reach rural towns that have access to internet services, this might be an effective training strategy for supplementing the intervention skills of social service workers who work with left behind children and their families.
Cases in the child welfare system involving caregiver substance use disorder(s) need new approaches.
Relationship-focused interventions offer new opportunities to keep families together during recovery and to improve child welfare outcomes.
Four innovative models: Project BRIGHT, Family-Based Recovery, C.A.R.E. and Mothering From the Inside Out are described.
Common mechanisms for change across models are identified: 1) increasing caregiver reflective functioning; 2) increasing caregiver and child emotional regulation capacities and; 3) increasing the quality of parent-child relationships through strengthening caregiver responsiveness, sensitivity, and attunement.
These targets contribute not just to greater parenting capacities but also to maintaining sobriety.
Acknowledgements:
The authors gratefully acknowledge: Dale H. Saul, Jeanette Radawich, Amy Myers, Michelle St. Pierre, Heather Simon, Jean Adnopoz, Cindy DeCoste, Jessica Borelli, Susan Bers, Lauren Dennehy, Naomi Libby Amanda Lowell, Linda Mayes, Amy Sommer, Eda Spielman, Karen Gould, Thomas McMahon, Steve Martino, Katie Arnone, Gweniver Bell, Christina Carlone, Rachel Dalton, Lourdes de las Heras, Hailey Dias, Ashley Winch, Carolynn Flynn, Peg Wright and participants and clinicians of Project BRIGHT, the CA.R.E. Model, Family-Based Recovery, and Mothering from the Inside Out for sharing their time and ideas.
Funding AcknowlDEgements: Funding for Project BRIGHT has been provided by the following grants: SAMHSA 1U79SM063114 (PI: Finkelstein) and HRSA R40MC31764 (PI: Paris). Funding for the C.A.R.E. Model has been provided by SAMHSA SM636062.Funding for Family-Based Recovery has been provided by the following grants: State of Connecticut and Social Finance LLC. Funding for Mothering from the Inside Out has been provided by the following grants: NIH/NIDA R01DA17294 (PI: Suchman), K02 DA023504 (PI: Suchman), K23 DA14606.
Footnotes
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Conflicts of interest
The authors have no conflicts of interest to report.
Recent work by Levy (2019) cautions against only viewing substance use solely through the lens of self-medication.
Contributor Information
Emily A. Bosk, Assistant Professor of Social Work, Rutgers University, the State University of New Jersey.
Ruth Paris, Associate Professor and Chair, Clinical Practice Department, Boston University School of Social Work.
Karen E. Hanson, Assistant Clinical Professor of Social Work, Yale University School of Medicine, Yale Child Study Center.
Debra Ruisard, Chief Clinical Officer, The Center for Great Expectations.
Nancy E. Suchman, Yale University School of Medicine, Department of Psychiatry and Yale Child Study Center
References
- Alvarez-Monjaras M, McMahon T, & Suchman N (2019). Does maternal reflective functioning mediate associations between representations of caregiving with maternal sensitivity in a high-risk sample?. Psychoanalytic Psychology, 36(1), 82–92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Barnard M, & McKeganey N (2004). The impact of parental problem drug use on children: what is the problem and what can be done to help? Addiction, 99(5), 552–559. doi: 10.1111/j.1360-0443.2003.00664.x [DOI] [PubMed] [Google Scholar]
- Beeghly M, Fuertes M, Liu CH, Delonis MS, & Tronick EZ (2011). Maternal sensitivity in dyadic context: Mutual regulation, meaning-making and reparation In Davis DW & Logsdon MC (Eds.), Psychology research progress. Maternal sensitivity: A scientific foundation for practice. Hauppauge, NY: Nova Science Publishers. [Google Scholar]
- Behnke M, & Smith VC (2013). Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics, 131(3), e1009–1024. doi: 10.1542/peds.2012-3931 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bernier A, Carlson S, & Whipple N (2010). From external regulation to self-regulation: Early parenting precursors of young children’s executive functioning. Child development, 81(1), 326–339. [DOI] [PubMed] [Google Scholar]
- Borelli JL, Crowley MJ, David DH, Sbarra DA, Anderson GM, & Mayes LC (2010). Attachment and emotion in school-aged children. Emotion, 10(4), 475–485. doi: 10.1037/a0018490 [DOI] [PubMed] [Google Scholar]
- Brems C, Johnson M, Neal D, & Freemon M (2004). Childhood abuse history and substance use among men and women receiving detoxification services The American Journal of Drug and Alcohol Abuse, 30(4), 799–821. [DOI] [PubMed] [Google Scholar]
- Chaplin TM, & Sinha R (2013). Stress and parental addiction In Suchman NE, Pajulo M, & Mayes L (Eds.), Parenting and Substance Abuse: Developmental Approaches to Intervention: Oxford University Press. [Google Scholar]
- Choi S, & Ryan J (2007). Co-occuring problems for substance abusing mothers in child welfare: Matching services to improve family reunification. Children and Youth Services Review, 29(11), 1395–1410. [Google Scholar]
- Doyle C, & Cicchetti D (2017). From the cradle to the grave: The effect of adverse caretiving environments on attachment and relationships throughout the lifespan. Clinical Psychology: Science and Practice, 24(2), 203–217. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Edwards EP, Homish GG, Eiden RD, Grohman K, & Leonard K (2009). Longitudinal prediction of early childhood discipline styles among heavy drinking parents. Addictive Behaviors, 34, 100–106. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Eiden RD, Colder C, Edwards EP, & Leonard KE (2009). A longitudinal study of social competence among children of alcoholic and nonalcoholic parents: role of parental psychopathology, parental warmth, and self-regulation. Psychol Addict Behav, 23(1), 36–46. doi: 10.1037/a0014839 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Eiden RD, Stevens A, Scheutze P, & Dombkowski LE (2006). Conceptual model for maternal behavior among polydrug cocaine-using mothers: the role of postnatal cocaine use and maternal depression Psychology of Addictive Behavior, 20, 1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Feldman R, Dolberg D, & Nadam R (2010). The expression and regulation of anger in toddlers: Relations to maternal behavior and mental representations Infant Behavior and Development, 2011(34), 310–320. [DOI] [PubMed] [Google Scholar]
- Flanagan J, Korte K, Killeen T, & Back S (2016). Concurrent treatment of substance use and PTSD. Current psychiatry reports, 18(8), 70. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Flykt M, Punamaki RL, Belt R, Biringen Z, Salo S, Posa T, & Pajulo M (2012). Maternal representations and emotional availability among drug-abusing and nonusing mothers and their infants. Infant Ment Health J, 33(2), 123–138. doi: 10.1002/imhj.21313 [DOI] [PubMed] [Google Scholar]
- Grella CE, & Stein JA (2006). Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders. Psychiatr Serv, 57(7), 1007–1015. doi: 10.1176/ps.2006.57.7.1007 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hanson KE, Duryea RR, Painter M, Vanderploeg JJ, & Saul DH (2019). Family-Based Recovery: An Innovative Collaboration between Community Mental Health Agencies and Child Protective Services to Treat Families Impacted by Parental Substance Use. Child Abuse Review (on-line). doi: 10.1002/car.254 [DOI] [Google Scholar]
- Hanson K, Saul D, Vanderploeg J, Painter M, & Adnopoz J (2015). Family-Based Recovery: An Innovative In-Home Substance Abuse Treatmetn Model for Families with Young Children. Child Welfare, 94(4). [PubMed] [Google Scholar]
- Hesse E, & Main M (2006). Frightened, Threatening, and Dissociative Parental Behavior: Theory and Associations with Parental Adult Attachment Interview Status and Infant Disorganization. Development and Psychopathology, 18, 309–343. doi:DOI: 10.10170S0954579406060172 [DOI] [PubMed] [Google Scholar]
- Huth-Bocks A, Muzik M, Beeghly M, Earls L, & Stacks AM (2014). Secure base scripts are associated with maternal parenting behavior across contexts and reflective functioning among trauma-exposed mothers. Attachment & Human Development, 16(6), 535–556. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kelley ML, Lawerence HR, Milletich RJ, Hollis BF, & Henson JM (2015). Modeling risk for child abuse and harsh parenting in families with depressed and substance-abusing parents Child abuse & neglect, 43(52), 42–52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Khantzian EJ (1997). The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harv Rev Psychiatry, 4(5), 231–244. doi: 10.3109/10673229709030550 [DOI] [PubMed] [Google Scholar]
- Kirst M, Aery A, Matheson F, & Stergiopoulos V (2017). Provider and consumer perceptions of trauma-informed practices and services for substance use and mental health problems. International Journal of Mental Health and Addiction, 15(3). [Google Scholar]
- Lieberman AF (2004). Traumatic stress and quality of attachment: Reality and internalization in disorders of infant mental health. Infant Mental Health Journal, 25(4), 336–351. [Google Scholar]
- Lieberman AF, & Van Horn P (2005). Don’t hit my mommy!: A manual for child-parent psychotherapy with young witnesses of family violence: Zero to Three. [Google Scholar]
- Lieberman AF, Van Horn P, & Ippen CG (2005). Toward evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44(12), 1241–1248. [DOI] [PubMed] [Google Scholar]
- Marsh JC, Smith BD, & Bruni M (2011). Integrated substance abuse and child welfare services for women: A progress review. Children and Youth Services Review, 33(3), 466–472. doi: 10.1016/j.childyouth.2010.06.017 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Minnes S, Singer LT, Arendt R, & Satayathum S (2005). Effects of prenatal cocaine/polydrug use on maternal-infant feeding interactions during the first year of life. J Dev Behav Pediatr, 26(3), 194–200. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Moss HB, Lynch KG, Hardie TL, & Baron DA (2002). Family functioning and peer affiliation in children of fathers with antisocial personality disorder and substance dependence: associations with problem behaviors. Am J Psychiatry, 159(4), 607–614. doi: 10.1176/appi.ajp.159.4.607 [DOI] [PubMed] [Google Scholar]
- Onken L, Carroll KM, Shoham V, Cuthbert B, & Riddle M (2014). Reenvisioning clinical science: unifying the discipline to improve public health Clinical Psychological Science, 2(1), 22–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pajulo M, Suchman NE, Kalland M, Sinkkonen J, Helenius H, & Mayes L (2008). Role of Maternal Reflective Ability for Substance Abusing Mothers. J Prenat Perinat Psychol Health, 23(1), 13–31. [PMC free article] [PubMed] [Google Scholar]
- Pajulo M, & Kalland M (2013). Mentalizingbased intervention with mother-baby dyads. S. 282–302 Suchman Teoksessa, Nancy & Pajulo, Marjukka & Mayes, Mayes Linda C. (eds.): Parenting and Substance Abuse. Developmental Approaches to Intervention [Google Scholar]
- Raby KL, Roisman GI, Fraley RC, & Simpson JA (2015). The enduring predictive significance of early maternal sensitivity: Social and academic competence through age 32 years. Child development, 86(3), 695–708. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rutherford H, Potenza MN, & Mayes L (2013). The Nuerobiology of Addiction and Attachment In Suchman NE, Pajulo M, & Mayes L (Eds.), Parenting and Substance Use: Developmental Approaches to Intervention: Oxford University Press. [Google Scholar]
- Slade A (2005). Parental Reflective Functioning: An Introduction. Attachment and Human Development, 7(3). doi: 10.1080/14616730500245906 [DOI] [PubMed] [Google Scholar]
- Slesnick N, Feng X, Brakenhoff B, & Brigham GS (2014). Parenting under the influence: The effects of opioids, alcohol and cocaine on mother-child interaction. Addictive Behaviors, 39(5), 897–900. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sokolowski MS, Hans SL, Bernstein VJ, & Cox SM (2007). Mothers’ representations of their infants and parenting behavior: Associations with personal and social contextual variables in a high-risk sample. Infant Mental Health Journal, 28(3), 344–365. [DOI] [PubMed] [Google Scholar]
- Suchman N, DeCoste C, Leigh D, & Borelli J (2010). Reflective functioning in mothers with drug use disorders: Implications for dyadic interactions with infants and toddlers. Attachment and Human Development, 12, 567–585. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Suchman NE, DeCoste C, Borelli JL, & McMahon TJ (2018). Does improvement in maternal attachment representations predict greater maternal sensitivity, child attachment security and lower rates of relapse to substance use? A second test of Mothering from the Inside Out treatment mechanisms. Journal of Substance Abuse Treatment, 85, 21–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Suchman NE, Borelli JL, & DeCoste CL (2018). Can addiction counselors be trained to deliverMothering from the Inside Out, a mentalization-based parenting therapy, with fidelity? Results from a community-based Stage III randomized clinical trial. Attachment & Human Development. DOI: 10.1080/14616734.2018.1559210 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Suchman NE, Decoste C, Rosenberger P, & McMahon TJ (2012). Attachment-Based Intervention for Substance-Using Mothers: A Preliminary Test of the Proposed Mechanisms of Change. Infant Ment Health J, 33(4), 360–371. doi: 10.1002/imhj.21311 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Suchman NE, DeCoste CL, McMahon TJ, Dalton R, Mayes LC, & Borelli J (2017). Mothering From the Inside Out: Results of a second randomized clinical trial testing a mentalization-based intervention for mothers in addiction treatment. Dev Psychopathol, 29(2), 617–636. doi: 10.1017/S0954579417000220 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Suchman NE, Mayes L, Conti J, Slade A, & Rounsaville B (2004). Rethinking parenting interventions for drug-dependent mothers: From behavior management to fostering emotional bonds. Journal of Substance Abuse Treatment, 27(3), 179–185. [DOI] [PubMed] [Google Scholar]
- Tronick EZ, Messinger DS, Weinberg MK, Lester B, LaGasse L, Seifer R, & Poole K (2005). Cocaine exposure is associated with subtle compromises of infants’ and mothers’ social-emotional behavior and dyadic features of their interaction in the face-to-face still face paradigm. Developmental Psychology, 41(5). [DOI] [PubMed] [Google Scholar]
- Van Der Kolk B (2017). Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401–408. [Google Scholar]
- Van Niel C, Pachter LM, Wade R Jr., Felitti VJ, & Stein MT (2014). Adverse events in children: predictors of adult physical and mental conditions. J Dev Behav Pediatr, 35(8), 549–551. doi: 10.1097/DBP.0000000000000102 [DOI] [PubMed] [Google Scholar]