PERINATAL AND FAMILY SERVICES

Pregnant and Parenting Women

This webpage identifies the major literature in the field of perinatal and family services: pregnant and parenting women. The time frame is from January 2000 through December 2014.

Allen, R. H. & Alpert, W. (2012). Maternal Drug Use and Its Effect on Neonates. OB/GYN Clinical Alert, 119(5), pp. 1-3.

The authors of this article sought to estimate trends in prenatal drug exposure and neonatal abstinence syndrome (NAS) in Washington State from 2000-2008/ they identified the types of drugs used, predictors of prenatal drug use and NAS, and outcomes of drug-exposed and NAS-diagnosed neonates. Results show that maternal use of illicit and prescription drugs was associated with considerable neonatal morbidity and significantly higher rates of drug exposure and neonatal abstinence syndrome in recent years. Data suggest that opioid analgesics contributed to the increase in prenatal drug exposure and neonatal abstinence syndrome in Washington State. The authors emphasize the need for clinicians to screen pregnant women for illicit and prescription drug use and minimize use of opioid analgesics during pregnancy.

Arria, M. A., Mericle, A. A., Meyers, K. & Winters, C. K. (2012). Parental substance use impairment, parenting and substance use disorder risk. Journal of Substance Abuse Treatment, 43(1), pp. 114–122. DOI: 10.1016/j.jsat.2011.10.001

This study investigated substance use disorder (SUD) among respondents with ages 15–54 years as a function of their parents' substance-related impairment and parents' treatment history. Results show that parental substance-related impairment was associated with SUD. Paternal treatment history was associated with a decreased risk for SUD but did not appear to be associated with positive parenting practices. Results suggest that parenting behaviors might operate differently to influence SUD risk in children where parents are affected by substance use problems. Future research is warranted to better understand the complex relationships among parental substance use, treatment, parenting behaviors, and SUD risk in offspring. Opportunities might exist within treatment settings to improve parenting skills.

Barlow, A., Mullany, B. C., Neault, N., Davis, Y., Billy, T., Hastings, R., Coho-Mescal, V…& Walkup, J. T. (2010). Examining correlations of methamphetamine and other drug use in pregnant American Indian adolescents. American Indian and Alaska Native Mental Health Research, 17(1), pp. 1-24.

American Indian and Alaska Native (AI/AN) adolescents have high rates of pregnancy, as well as alcohol, marijuana, cocaine, and, increasingly, methamphetamine (meth) use. The progression of adolescent drug use to meth use could have devastating impacts on AI communities, particularly when youth are simultaneously at risk for teen childbearing. In order to inform future prevention efforts, this study explores correlates of meth use in a sample of pregnant AI teens, with a focus on sociodemographic, familial, and cultural factors and use of other drugs.

Benoit, C., Stengel, C., Marcellus, L., Hallgrimsdottir, H., Anderson, J., MacKinnon, K., Phillips, R… & Charbonneau, S. (2014). Providers’ constructions of pregnant and early parenting women who use substances. Sociology of Health & Illness, 36(2), pp. 252-263. DOI: 10.1111/1467-9566.12106

This article reviews literature and focuses on providers’ conceptualizations of problematic substance by women during pregnancy and early parenting. Our results show that most study participants regard any substance use during pregnancy, birth and the postpartum period as fundamentally unacceptable. This framing of problematic substance use is accomplished via gendered responsibility of women as fetal incubators and primary caregivers of infants. Authors suggest that intervention programs should be grounded should move away from a focus on health behavior and instead focus health-related practices.

Berlin, L. J., Shanahan, M., & Carmody, K. A. (2014). Promoting supportive parenting in new mothers with substance-use problems: a pilot randomized trial of residential treatment plus an attachment-based parenting program. . Infant Mental Health Journal, 35(1), pp 81-85. DOI: 10.1002/imhj.21427

This article presents the results of a pilot program which supplements residential substance-abuse treatment for new mothers with a brief, yet rigorous, attachment-based parenting program. The results of the pilot program reflect that attachment-based services may have particular leverage for breaking intergenerational cycles of maltreatment. The authors suggest there are many potential benefits of supplementing residential substance-abuse treatment with brief, attachment-based interventions.

Blakey, M. J. (2012). From surviving to thriving: Understanding reunification among African American mothers with histories of addiction. Children and Youth Services Review, 34(1), pp. 91–102. DOI: 10.1016/j.childyouth.2011.09.006

This study uses the Multiple Embedded Case Study method to study the experiences and feelings of African American mothers struggling to overcome addiction and highlights the main differences between women who regained custody and those who permanently lost custody of their children. The women who lost custody of their children tended to be in survival mode, characterized as going through the motions, engaging in acting-out behaviors, and failing to follow treatment recommendations. The women who regained custody of their children tended to thrive and characterized as having internal motivation, taking responsibility, and engaging the material. This study advances our knowledge of the factors contributing to reunification.

Borelli, J. L., & West, J. L. (2012). Emotionally avoidant language in the parenting interviews of substance-dependent mothers: associations with reflective functioning, recent substance use, and parenting behavior. Infant Mental Health Journal, 33(5), pp. 506–519 DOI: 10.1002/imhj.21340

In this study, we examine substance -abusing mothers’ (positive and negative) emotion language word use during their discussion of negative parenting experiences on the Parent Development Interview for its association with reflective functioning (RF), recent substance-use history, and sensitivity to child cues. Results of the study suggest that more frequent positive feeling word use, but not negative emotion word use, is associated with lower RF, more recent substance use, and lower sensitivity to child cues. Positive feeling word use partially mediates the association between self-focused RF and insensitive parenting.

Brake field, T., Wilson, H., & Donenberg, G. (2012). Maternal models of risk: Links between substance use and risky sexual behavior in African American female caregivers and daughters. Journal of Adolescence, 35(4), pp. 959–968. DOI: 10.1016/j.adolescence.2012.01.004

This paper examines pathways from female caregivers’ risky sexual behavior and substance use to adolescent girls’ risky sexual behavior and substance use. Results of the study suggest that sexual risk reported by female caregivers was associated with adolescent sexual risk, and illicit drug use reported by female caregivers was related to adolescent-reported substance use, which was in turn associated with adolescent-reported sexual risk behavior. These findings suggest that female caregivers’ sexual behavior and substance use both relate to girls’ sexual risk. Thus, results emphasize the role of female caregivers in transmitting risk.

Brigham, G., Winhusen, T., Lewis, D., & Kropp, F. (2010). Incentives for retention of pregnant substance users: A secondary analysis. Journal of Substance Abuse Treatment, 38(1), pp. 90.

This article presents the findings of a multisite clinical trial. 200 pregnant substance users entering outpatient treatment at one of four programs were randomized to either three individual sessions of Motivational Enhancement Therapy for Pregnant Substance users or three individual sessions normally provided. Retail scrip from $25 to $30 was provided for attendance of research visits but not treatment visits. A post hoc analysis of the non-methadone-maintained participants (n = 175) evaluated the hypotheses that monetary reinforcement for attendance would result in more consecutive, and overall, weeks of attendance of research versus non-incentivized treatment visits. Findings indicate participants were nearly three times as likely to attend 4 consecutive weeks of research visits versus treatment sessions. There was no effect for income while fewer dependents were associated with more consecutive weeks of attendance. Incentives in the $25-to-$30 range may serve to significantly increase attendance and retention.

Chang, J. C., Dado, D., Frankel, R. M., Rodriguez, K. L., Zickmund, S., Ling, B. S., & Arnold, R. M. (2008). When pregnant patients disclose substance use: Missed opportunities for behavioral change counseling. Patient Education & Counseling, 72(3), pp. 394-401.

The first obstetric visit is an opportunity to provide counseling to women with substance abuse risks, including smoking, drug use, and alcohol use. The objective of this study was to examine patient–provider communication about substance use behaviors during the first obstetric visit who present with substance abuse risks, including smoking, drug use, and alcohol use. Twenty-nine providers (21 residents, 5 midwives, 3 nurse practitioners) and 51 patients participated in the study. Twenty-five patients were smokers, 4 used alcohol, and 11 used drugs. Provider responses to smoking disclosures included discussions of risks, encouragement to quit-cut down, affirmation of attempts to quit-cut down, and referral to smoking cessation programs. Responses to alcohol or drug disclosures included only a general statement regarding risks and referral to genetics. The findings suggest that providers were less attentive to alcohol and drugs than smoking where they had pre-established patterns of response. The authors recommend providers should discuss behavioral change strategies and motivations with pregnant patients who use drugs and/or alcohol as well as those who smoke.

Chuang, E., Wells, R., Bellettiere, J., & Cross, T. P. (2013). Identifying the substance abuse treatment needs of caregivers involved with child welfare. Journal of Substance Abuse Treatment, 45(1), pp. 118-125.

This study examined how agency use of standardized substance use assessments and child welfare investigative caseworker education, experience, and caseload affected caseworkers' identification of parental substance abuse treatment needs. Data was collected from a national probability sample of permanent, primary caregivers involved with child protective services whose children initially remained at home and whose confidential responses on two validated instruments indicated harmful substance use or dependence. Investigative caseworkers reported use of a formal assessment in over two thirds of cases in which substance use was accurately identified. Caseworkers were also less likely to identify substance abuse when their caseloads were high and when caregivers were fathers. Implications for agency practice are discussed.

Clark, H.W. (2001). Residential substance abuse treatment for pregnant and postpartum women and their children: Treatment and policy implications. Child Welfare, 80(2), pp. 179-198.

In FY 1993 and FY 1995, the federal government awarded 27 five-year grants that supported 35 residential treatment projects for substance-abusing pregnant and postpartum women (PPW) and their children. These projects provided comprehensive, culturally competent, and gender-sensitive treatment. Preliminary findings indicate that comprehensive residential treatment in which infants and young children live with their mothers is a promising approach for alleviating the women’s substance abuse and other problems, improving birth outcomes, and helping these mothers become more competent parents. These programs also help the women reduce substance use, avoid criminal activity, and become responsible wage earners. The findings from the PPW program demonstrate the importance of treatment services for these families and it appears that intensive, comprehensive, and prolonged residential services are effective for women with multiple, serious needs, with benefits for both mothers and children. Future cost data are expected to demonstrate the efficiencies and benefits of these projects compared to no treatment.

Connors-Burrow, N. A., McKelvey, L., Pemberton, J. R., Lagory, J., Mesman, G. R., & Whiteside-Mansell, L. (2013). Moderators of the relationship between maternal substance abuse symptoms and preschool children’s behavioral outcomes. Journal of Child and Family Studies, 22(8), pp. 1120-1129. DOI: 10.1007/s10826-012-9674

The purpose of this study is to examine harsh parenting and family conflict as potential moderators of the relationship between symptoms of maternal substance use problems and child externalizing behavior problems. This study utilized data collected during two home visits, an average of 10 months apart, with data on family functioning and maternal symptoms of substance use problems collected at the first time point and child externalizing behavior collected at the second time point. Over one-third of the children (38.1 %) had clinically elevated externalizing behavior scores. Results reflect that in the absence of family risks related to harsh parenting and family conflict, maternal symptoms of substance use problems did not have a significant impact on child externalizing behavior in preschool children. However, when high levels of family conflict or harsh parenting were present, symptoms of maternal substance use problems increased the risk of externalizing behavior problems in children.

Denton, W. H., Adinoff, B. H., Lewis, D., Walker, R., & Winhusen, T. (2014). Family discord is associated with increased substance use for pregnant substance users. Substance Use & Misuse, 49(3), pp. 326-332.

This study examined the relationship of baseline family discord to substance use and treatment session attendance. Family discord was assessed using items from the family composite of the Addiction Severity Index. Women with family discord were more likely to report living with a problematic substance user, reported a higher percentage of substance use days throughout each study phase, had a greater proportion of positive UDS over the four-month study period, and attended more weeks of treatment during the first month. Specific treatment interventions targeting pregnant women with family discord may be warranted.

Grant, T., Graham, J. C., Ernst, C, C., Peavy, K. M., & Brown, N. N. (2014). Improving pregnancy outcomes among high-risk mothers who abuse alcohol and drugs: Factors associated with subsequent exposed births. Children and Youth Services Review, 46(1), pp. 11-18.

This longitudinal study explores whether loss of an index child due to substance abuse is associated with risk of a subsequent alcohol/drug-exposed birth in a sample of 795 substance-abusing mothers enrolled in the Washington State Parent–Child Assistance Program (PCAP). Results show that at program exit, approximately 1/3 of the women in the study had a subsequent birth, among these, over half, used alcohol, and/or drugs during that pregnancy. Additionally, for women with subsequent births, the adjusted odds of having an exposed child were increased three-fold if the index child had been removed from the mother’s care.

Goddard, K. (2009). Pregnancy and its effects on opiate and alcohol use. Drugs and Alcohol Today, 9(4), pp. 18.

This study explores how the provision of opiate substitution therapy to pregnant women could achieve a reduction in heroin use. It further explores whether such a reduction is accompanied by an increase in alcohol consumption, and concludes that women do not substitute decreased opiate use with increased alcohol consumption during pregnancy. Thirty women who had been pregnant and in drug treatment at a community drug team in Dudley West Midlands agreed to participate in this study. For many, this was an opportunity to express their fears and anxieties about being drug-using mothers and being in drug treatment. Data collection methods included semi-structured interviews and collection of urine samples.

Goler, N. C., Armstrong, M. A., Taillac, C. J., & Osejo, V. M. (2008). Substance abuse treatment linked with prenatal visits improves perinatal outcomes: A new standard. Journal of Perinatology, 28(9), pp. 597-603.

This study evaluates the impact of Early Start, an obstetric clinic-based prenatal substance abuse treatment program, on perinatal outcomes. Participants included 985 women who completed Prenatal Substance Abuse Screening Questionnaires at obstetric clinics between 1 January 1999 and 30 June 2003, had urine toxicology screening tests and either live births or intrauterine fetal demises (IUFDs). Four groups were compared: women screened/assessed positive and treated by Early Start (‘SAT’, n=2073); women screened/assessed positive without treatment (‘SA’, n=1203); women screened positive only (‘S’, n=156); controls who screened negative (n=46 553). Ten neonatal and maternal outcomes were studied. Results of the study reflect that SAT women had either similar or slightly higher rates than the control women on most outcomes but significantly lower rates than S women. SA women generally had intermediate rates to the SAT and S groups. The authors conclude that substance abuse treatment integrated with prenatal visits was associated with a positive effect on maternal and newborn health.

Graff, F. S., Morgan, T. J., Epstein, E. E., McCrady, B. S., Cook, S. M., Jensen, N. K., & Kelly, S. (2009). Engagement and retention in outpatient alcoholism treatment for women. American Journal on Addictions, 18(4), pp. 277-288.

This article presents the findings of a study of 102 women and their partners randomized to individual or couples outpatient alcoholism treatment. Women attended more treatment sessions if they were assigned to individual treatment, older, had fewer symptoms of alcohol dependence, had more satisfying marital relationships, had spouses who drank, and had matched preference for treatment condition. Women were more engaged in treatment (IE, completed more assigned homework) if they had fewer children at home, fewer alcohol dependence symptoms, later age of onset of alcohol diagnosis, more satisfying marital relationships, and spouses who accepted or encouraged their drinking. Results highlight important associations of treatment and relationship variables with treatment retention and engagement.

Grella, C. E., Hser, Y., & Huang, Y. (2006). Mothers in substance abuse treatment: Differences in characteristics based on involvement with child welfare services. Child Abuse & Neglect, 30(1), pp. 55-73.

In this article, the authors compare the characteristics of mothers in substance abuse treatment who were and were not involved with child welfare services, and discusses the treatment implications of these differences. Data were obtained from a statewide treatment outcome monitoring project in California. Clients were assessed at treatment admission using the Addiction Severity Index. The authors found that mothers who were involved with child welfare were younger, had more children, and had more economic problems. They were more likely to be referred by the criminal justice system or other service providers, to have a history of physical abuse, and to be treated in outpatient programs. They had lower levels of alcohol severity, but did not differ with regard to psychiatric severity or criminal involvement. Primary users of methamphetamine were disproportionately represented among this group and had a distinct profile from primary alcohol- and opiate-users. The authors conclude that mothers involved with child welfare enter substance abuse treatment through different avenues and present a clinical profile of treatment needs related to exposure to physical abuse, economic instability, and criminal justice involvement.

Haight, W. L., Carter-Black, J. D., & Sheridan, K. (2009). Mothers' experience of methamphetamine addiction: A case-based analysis of rural, Midwestern women. Children & Youth Services Review, 31(1), pp. 71-77.

According to the authors engaging mothers who are abusing methamphetamine in services is an important goal for rural child welfare. In this article, four rural, white, mothers in recovery from methamphetamine addiction described their life experiences through in-depth interviews. Three of the women grew up with parents who abused drugs, and all had experienced trauma as children and used other illegal drugs before methamphetamine. Mothers vividly portrayed the rapid loss of control that can occur with methamphetamine use, as well as the power of the addiction. They became “obsessed” with the drug and nothing was more important to them, not even the children whom they loved. They lost the ability to think “rationally,” experienced serious lapses in judgment, lost motivation, and lived in a “fog.” They described their illness as impacting their children's physical and psychological well-being including through exposure to domestic violence, adult substance abuse and other anti-social behavior, and loss of important relationships. They expressed concern that their children would abuse drugs. Women described recovery as possible only with significant external support, and they reported lasting physical, psychological and social side effects of their illness. Understanding mothers' experience of methamphetamine addiction can increase our awareness of this illness thereby reducing stigma and suggesting strategies for engaging them in intervention.

Harris, M. S. (2008). Alcohol, child maltreatment, and parenting stress in the lives of birth mothers. Journal of Human Behavior in the Social Environment, 18(2), pp. 129-150.

This exploratory study examines the potential relationship between parenting stress, child maltreatment, and alcoholism in a pilot data set. Twenty-four participants (six African-American, six European-American, six Mexican-American, and six Native-American) completed four questionnaires (Parenting Stress Index, Conflict Tactics Scale Parent-Child, and Michigan Alcoholism Screening Test, Chemical Dependency Assessment Profile [PSI, CTSPC, MAST, and CDAP]). Through principle component analyses and multiple regression analyses, it was suggested that self-perceived parenting strength or competence directly affect a parent's tactics to deal with parent-child conflicts. Results indicated that self-confidence as a competent parent was related to the frequency of using verbal degrading and physical punishment. Parents who reported that the child's temperament bothers them a lot were more likely to physically abuse the child. Though all the participants could be categorized as alcoholic by the MAST, parents' alcoholic abuse did not appear to elevate the severity of child maltreatment, as measured by the CTSPC.

Havens, J. R., Simmons, L. A., Shannon, L. M., & Hansen, W. F. (2009). Factors associated with substance use during pregnancy: Results from a national sample. Drug & Alcohol Dependence, 99(1-3), pp. 89-95.

The objective of this study was to examine the prevalence and correlates of substance use during pregnancy among women in the United States. The authors analyzed data from pregnant (n =1800) and non-pregnant women (n =37,527) aged 15–44 years who participated in the 2002 or 2003 National Survey on Drug Use and Health, a nationally representative epidemiologic survey. Study variables included demographics, any substance use in the prior 30 days, and possible current psychopathology. Results show that the prevalence of substance use among women in their first trimester, use was significantly lower among women in their second or third trimesters. Women who reported using substances during pregnancy were significantly more likely to meet the criteria for possible current psychopathology and be White. The authors conclude that the prevalence of substance use among pregnant women was significantly lower than non-pregnant women, some groups of women remain vulnerable to continued use, including those who are unemployed, unmarried, and experiencing possible current psychopathology. Prevention and intervention programs aimed at high-risk populations are warranted to reduce the deleterious effects of substance use on pregnancy outcomes.

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Holden, K. B., McKenzie, R., Pruitt, V., Aaron, K., & Hall, S. (2012). Depressive symptoms, substance abuse, and intimate partner violence among pregnant women of diverse ethnicities. Journal of Health Care for the Poor and Underserved, 23(1), pp. 226-241. DOI: 10.1353/hpu.2012.0022.

This study examines the relationship between self-reported depressive symptoms, substance abuse and intimate partner violence among 602 African American, Hispanic, White, Asian American, American Indian/Alaskan Native, Native Hawaiian/Pacific Islander pregnant women. Findings of the study are intended to inform strategies for community-based programs to better assist women of diverse ethnicities with addressing depression, substance abuse, and intimate partner violence during their pregnancies, with the ultimate aim of improving health and mental health outcomes for women and children.

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Hser, Y.I., & Niv, N. (2006). Pregnant women in women-only and mixed-gender substance abuse treatment programs: A comparison of client characteristics and program services. Journal of Behavioral Health Services & Research, 33(4), pp. 431-442.

This study compared characteristics of pregnant women treated in women-only (WO) and mixed-gender (MG) substance abuse treatment programs and compared services provided by these two types of programs. Participants were 407 pregnant women who were admitted to 7 WO programs and 29 MG programs in 13 counties across California during 2000-2002. Pregnant women treated in WO programs demonstrated greater severity in drug use, legal problems, and psychiatric problems than those treated in the MG programs. They were also less likely to be employed and more likely to be homeless. Women-only programs were more likely to offer child care, children's psychological services, and HIV testing. The greater problem severity of pregnant women treated in WO programs suggests that these specialized services are filling an important gap in addiction services, although further expansion is warranted in psychiatric, legal, and employment services.

Hser, Y., Kagihara, J., Huang, D., Evans, E., & Messina, N. (2012). Mortality among substance-using mothers in California: A 10-year perspective study. Addiction, 107(1), pp. 215-222. DOI: 10.1111/j.1360-0443.2011.03613.x

This study’s goal was to examine mortality rates and causes of death among a cohort of substance-using mothers and to identify risk factors that predict mortality. At the end of the study in 2010, 194 deaths were confirmed, corresponding to a crude mortality rate of 4.47 per 1000 person-years. Drug overdose (28.8%), cardiovascular disease (10%), and alcohol or drug disorders (8.9%) were the leading causes of death. Baseline factors associated with higher mortality included older age, being white (relative to African American or Hispanic), heroin, alcohol, cocaine or marijuana (relative to methamphetamine) as the primary drug problem, drug injection and greater severity of employment, medical/health and psychiatric problems. The authors conclude that substance-using mothers have 8.4 times the mortality than that observed among US women of similar age.

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Huizink, A. C. (2009). Moderate use of alcohol, tobacco and cannabis during pregnancy: New approaches and update on research findings. Reproductive Toxicology, 28(2), pp. 143-151. DOI: 10.1016/j.reprotox.2009.04.010

Interest in fetal origins of adverse offspring outcomes has grown extensively in the last decade. This has resulted in many published studies focusing on exposure in utero to substances and human offspring outcomes. Exposure to maternal substance use in pregnancy is believed to be a preventable hazard, and is therefore a main issue for public health concern and policy. However, an important question in human studies remains whether prenatal substance use exposure has an etiological role in pathways to adverse developmental and behavioral outcomes via teratological effects. Recent insights and developments in research methodology will aid the adequate and more refined testing of associations between prenatal substance use and offspring outcomes. In particular, novel approaches could assist in disentangling the exposure to substance effects from correlated risk factors. The purpose of this manuscript is therefore to provide an overview of methodological issues involved in studies that focus on the association between maternal substance use during pregnancy and offspring’s outcomes, to describe novel approaches to test these associations, and present some examples of new and well-designed studies and discuss their findings.

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Hunter, B. A., Jason, L. A., & Keys, C. B. (2013). Factors of empowerment for women in recovery from substance use. American Journal of Community Psychology, 51(1-2), pp. 91-102. DOI: 10.1007/s10464-012-9499-5

This article explored the factor structure of a modified empowerment scale with women in recovery from substance use who lived in recovery homes located throughout the United States. Results identified three factors of psychological empowerment which were closely related to previous conceptualizations of psychological empowerment: self-perception, resource knowledge and participation. Further analyses demonstrated a hierarchical relationship among the three factors, with resource knowledge predicting participation when controlling for self-perception. Finally, a correlational analysis demonstrated the initial construct validity of each factor, as each factor of empowerment was significantly and positively related to self-esteem. Implications for the application of psychological empowerment theory and research are discussed.

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Jones, H. E., Martin, P. R., Heil, S. H., Kaltenbach, K., Selby, P., Coyle, M. G., Stine, S. M…& Fischer, G. (2008). Treatment of opioid-dependent pregnant women: Clinical and research issues. Journal of Substance Abuse Treatment, 35(3), pp. 245-259.

This article addresses common questions that clinicians face when treating pregnant women with opioid dependence. Guidance, based on both research evidence and the collective clinical experience of the authors, which include investigators in the Maternal Opioid Treatment: Human Experimental Research (MOTHER) project is provided to aid clinical decision making. The MOTHER project is a double-blind, double-dummy, flexible-dosing, parallel-group clinical trial examining the comparative safety and efficacy of methadone and buprenorphine for the treatment of opioid dependence in pregnant women and their neonates. The article begins with a discussion of appropriate assessment during pregnancy and then addresses clinical management stages including maintenance medication selection, induction, and stabilization; opioid agonist medication management before, during, and after delivery; pain management; breast-feeding; and transfer to aftercare. Lastly, other important clinical issues including managing co-occurring psychiatric disorders and medication interactions are discussed.

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Jones, H. E., Finnegan, L. P., & Kaltenbach, K. (2012). Methadone and buprenorphine for the management of opioid dependence in pregnancy. Drugs, 72(6), pp. 747-757.

This article presents the findings of a literature review on the research on women maintained on methadone or buprenorphine during pregnancy, with a focus on the comparative effectiveness of methadone and buprenorphine pharmacotherapy. According to the findings of this study, buprenorphine appears less sedating than methadone on the fetus and finally the authors suggest that any treatment plan must be developed in the context of comprehensive care program that is sensitive to women-specific needs.

Jones, H. E., Heil, S. H., Baewert, A., Arria, A. M., Kaltenbach, K., Martin, P. R., Coyle, M. G…Fischer, G. (2012). Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction, 107(Supplement 1), pp. 5-27. DOI: 10.1111/j.1360-0443.2012.04035.x

This article presents the results of a literature review on the outcomes following maternal treatment with buprenorphine in maternal efficacy, fetal effects, neonatal effects, effects on breast milk and longer-term developmental effects. According to the authors treatment with buprenorphine is comparable to methadone, however difficulties exist with current buprenorphine induction methods.

Jos, A. C., Cooper-Saddle, S., & Stillwell, D. H. (2014). Advancing current treatments: Women, poverty, and co-occurring disorders. Journal of Feminist Family Therapy, 25(3), pp. 165-182. DOI: 10.1080/08952833.2013.777880

This article aims to conceptually advance current treatments for women in poverty experiencing the co-occurring effects of trauma and substance abuse by employing both systemic and feminist perspectives. Treatment of individuals dealing with substance abuse and trauma has revealed reciprocity between the two experiences. Therefore, in order to be effective, it is crucial that treatment takes this relationship into account. By analyzing the case study of one client, Jenny, current treatment models and societal understandings of women with co-occurring disorders will be addressed and challenged. The evidence indicates that integrative treatment plans will be enhanced with the additional aftercare inclusions of intensive case management, Dual Recovery Anonymous, and family therapy.

Kerwin, M. E. (2005). Collaboration between child welfare and substance-abuse fields: Combined treatment programs for mothers. Journal of Pediatric Psychology, 30(7), pp. 581-597.

This article provides a review of collaboration between child welfare and drug-abuse fields in providing treatment to mothers who abuse drugs and maltreat their children. A literature review of studies examining effects of maternal drug abuse on parenting skills and outcomes of interventions for both maternal drug abuse and parenting skills is provided. Results indicate that parenting skills differ between mothers who do and do not abuse drugs, but these studies are primarily limited to mothers of infants and preschoolers. The author finds that the evidence base for interventions to address both substance use and parenting in these mothers is growing, but more well-controlled studies are needed. Opportunities for improved collaboration between fields are presented. The author concludes that progress has been made toward collaboration to address drug abuse and parenting skills of mothers who abuse drugs, but more integrated strategies are needed, especially for mothers who use drugs and maltreat their children.

Kettinger, L. A., Nair, P., & Schuler, M. E. (2000). Exposure to environmental risk factors and parenting attitudes among substance-abusing women. American Journal of Drug and Alcohol Abuse, 26(1), pp. 1-11.

This study examined the amount of exposure to negative environmental risks and their association with parenting attitudes among a group of 198 inner city substance-abusing women. Mothers were recruited at delivery and were part of a randomized longitudinal intervention study for substance-abusing women and their infants. When the infants were 18 months old, a cumulative environmental risk score was calculated for each mother based on nine factors: violence (both domestic and environmental), depression, homelessness, incarceration, number of children, life stress, psychiatric problems, and absence of significant other. Based on their cumulative scores, mothers were placed in a low or high environmental risk group. Mothers in the high-risk group had fewer years of education, were younger when their first child was born, and had significantly worse scores on parenting attitude scales. Given the current state of welfare reform, it is important to determine which factors besides maternal substance abuse place these mothers at risk for poor parenting.

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King, P. A. L., Duan, L., & Amaro, H. (2014). Clinical needs of in-treatment pregnant women with co-occurring disorders: implications for primary care. Maternal Child Health Journal, 19(1), pp. 180-187. DOI: 10.1007/s10995-014-1508-x

The objective of this study was to provide primary care providers with insight into the needs of pregnant patients with high behavioral health risks to serve them better during a window of opportunity for long-term impact. Findings show that interpersonal abuse was associated with increased mental health and trauma symptomatology but not with alcohol or drug abuse severity among pregnant women.

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Knight, D. K., Logan, S. M., & Simpson, D. D. (2001). Predictors of program completion for women in residential substance abuse treatment. American Journal of Drug and Alcohol Abuse, 27(1), pp. 1-18.

Although there is increasing emphasis on providing drug treatment programs for women that address their specific needs (including parenting and childcare), some women still fail to complete treatment. Because of the limited information about the barriers involved, this study examines pretreatment characteristics as predictors of program completion for 87 women who were pregnant or who entered residential treatment with their children. Women who completed program requirements were more likely to have a high school degree or equivalent, no arrests in the 6 months before admission, and friends who were less deviant. These findings support the need for specialized education and services that address social deviancy of pregnant and/or parenting women.

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Kovalesky, A. (2001). Factors affecting mother-child visiting identified by women with histories of substance abuse and child custody loss. Child Welfare, 80(6), pp. 749-768.

The influence of maternal substance abuse upon the placement of children in out-of-home care increased significantly in the 1980s and 1990s, affecting mother-child visiting in numerous ways. The present study sought to identify factors that affect mother-child visiting when maternal substance abuse is a contributing reason to the placement of a child in out-of-home care. Content analysis of interview data from 15 mothers with histories of illegal drug use and child custody loss provides insight into five major factors that can promote or inhibit visiting: (1) mother's drug use and health status, (2) effects of visits on the child, (3) transportation, (4) scheduling/visit settings, and (5) support of others. The authors conclude that if treatment for the mother’s substance abuse problem is not imminently available following child custody loss, the mother may find it difficult to maintain her abstinence for visits with her child. In addition, the visits themselves can elicit such strong emotional responses regarding custody loss that a relapse can occur following a visit. The authors state that ready access to a counselor, 12-step sponsor, substance abuse treatment program, or other source of support is essential to promoting mother-child visiting.

Lam, W. K. K., Wechsberg, W., & Zule, W. (2004). African-American women who use crack cocaine: A comparison of mothers who live with and have been separated from their children. Child Abuse & Neglect, 28(11), pp. 1229-1247.

This study examined factors that influenced caregiver status for African-American mothers who use crack cocaine but are not receiving drug treatment and participated in an HIV prevention study in North Carolina. This study fills an important gap of the literature by examining factors that affect whether mothers retain care of their children among a rarely studied sample of African American women who actively abuse drugs but are not connected to formal service or welfare systems. Caregiver mothers who were living with at least one of their children were compared with non-Caregivers who were separated from all of their children. Non-Caregivers were more likely to be older, to have been physically abused as children, to trade sex more frequently, to be homeless, and to have no health insurance, report higher frequencies of drug use, risky sex practices, psychological distress, and victimization experiences. Findings that socio-environmental factors were more strongly associated with caregiver status than crack use underscore the importance of contextual issues such as housing, victimization history, and resources in serving maternal crack users. This article suggests that community outreach and interventions that engage mothers who use drugs and live with their children may be more effective strategies than formal office-based services to link mothers who use crack and their children to needed drug treatment and family and child services.

Light, K. C., Grewen, K. M., Amico, J. A., Boccia, M., Brownley, K. A., & Johns, J. M. (2004). Deficits in plasma oxytocin responses and increased negative affect, stress, and blood pressure in mothers with cocaine exposure during pregnancy. Addictive Behaviors, 29(1), pp. 1541-1564.

In this article, the authors analyzed oxytocin, blood pressure (BP), maternal behavior, and affect in mothers of infants who used cocaine or did not during pregnancy, to determine if cocaine use would disrupt oxytocin activity and increase maternal neglect. Findings reflected that in the experimental group, the women had lower oxytocin levels, grater hostility and depressed mood, less support from others and mastery over life events, higher BP during all events of testing without the baby and higher ambulatory BP and urinary norepinephrine at home, however findings also reflected that holding their babies decreased BP in these women who then did not differ from the control group or observed affect.

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Linden, I., Torchalla, I., & Krausz, M. (2013). Addiction in maternity: Prevalence of mental illness, substance use, and trauma. Journal of Aggression, Maltreatment & Trauma, (22)1, pp. 1070-1084.

This study looks at the social and mental health characteristics of substance-using women during maternity in Vancouver. It provides a comprehensive understanding of the experience and impact of substance abuse and mental health in pregnancy and after birth. Results of the study are used to suggest more trauma training is needed for treatment providers in order to provide the best possible care to this population.

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Martin, C. E., Longinaker, N., Terplan, M. (2014). Recent trends in treatment admissions for prescription opioid abuse during pregnancy. Journal of Substance Abuse Treatment, 48(1), pp. 37-42.

This article investigated recent trends in substance abuse treatment admissions for prescription opioids during pregnancy using the Treatment Episodes Data Set. From 1992 to 2012 the overall proportion of pregnant admissions remained stable at 4%; however, admissions of pregnant women reporting prescription opioid abuse increased substantially from 2% to 28% especially in the south. Demographic characteristics of pregnant opioid admissions changed from 1992 to 2012 with younger, unmarried White non-Hispanic women, criminal justice referrals, and those with a psychiatric co-morbidity becoming more common. About a third received medication assisted therapy despite this being the standard of care for opioid abuse in pregnancy. Substance abuse treatment centers have increased treatment volume to address the increase in prescription opioid dependence among pregnant women, with an emphasis on targeting certain risk groups and increasing utilization of medication assisted therapy.

Massey, H. S. Neiderhiser, M. J., Shawc, S. D., Leve, D. L., Ganiban, M. J., & Reiss, D. (2012). Maternal self-concept as a provider and cessation of substance use during pregnancy. Addictive Behaviors, 37(8), pp. 956-961. DOI: 10.1016/j.addbeh.2012.04.002

The goal of this study was to show how self-concept associated with pregnancy may influence motivation to stop substance use. More positive self-concept as an adequate provider was independently associated with cessation of substance use and earlier initiation of prenatal care during pregnancy. Familial substance abuse, depressive symptoms, and antisocial behaviors during pregnancy, were also independent predictors, and more strongly associated with cessation. The authors state that enhancing maternal identity as a provider for the fetus during pregnancy, along with treatment of depression, may improve motivation to stop substance use.

May, P. A., Miller, J. H., Goodhart, K. A., Maestas, O. R., Buckley, D., Trujillo, P. M., & Gossage, J.P. (2008). Enhanced case management to prevent fetal alcohol spectrum disorders in Northern Plains communities. Maternal & Child Health Journal, 12(6), pp. 747-759.

Women proven to be extremely high risk for drinking during pregnancy were provided case management (CM) enhanced with strategies derived from motivational interviewing (MI) as a part of a comprehensive Fetal Alcohol Syndrome (FAS) epidemiology and prevention program in four American Indian communities in Northern Plains states. At intake, 24% of CM clients reported binge drinking one or more days in the preceding week. Data were collected at 6 month intervals from 6 to 72 months after enrollment. Consumption of alcohol, as measured by both quantity and frequency measures, was reduced at 6 months. Thirty-eight percent of enrolled women reported complete abstinence from alcohol use at 6 months, and the number of binges while drinking in CM declined significantly from 15 at baseline to 4.3 at 6 months. However, mean peak BACs for the heavy drinking sessions were still problematic for those who continued to drink. They ranged from .234 to .275 from baseline to 12 month follow-up, but the total number of binges was reduced substantially at 12 months as well. Furthermore, the most important outcomes are the status of the children born while in CM.

Mayet, S., Groshkova, T., Morgan, L., Maccormack, T., & Strang, J. (2008). Drugs, alcohol and pregnant women — changing characteristics of women engaging with a specialist perinatal outreach addictions service. Drug & Alcohol Review, 27(5), pp. 490-496.

The aim of this study was to investigate changes in the characteristics of women referred to a specialist perinatal addictions outreach service (1989-1991 versus 2002-2005). A cross-sectional audit of health records was conducted to gather information for each woman who contacted the service (2002-2005). Data were compared to an earlier study in the same locality (1989-1991). A total of 167 pregnant substance-using women were referred between 2002 and 2005, of whom 126 made contact. The mean age was 30.2 years at 20.8 weeks' fetal gestation, with 76% not in addictions treatment, 32% from black or minority ethnic (BME) communities, 49% polysubstance users and 29% homeless. The primary substance used was illicit heroin (38%), followed by cocaine (24%). Compared to 1989-1991, there were significantly more pregnant women presenting at an older age, later gestation, with increased polysubstance use and a higher percentage of women from BME communities. This service was able to access vulnerable substance-abusing women with an altered pattern of substance use compared to over 10 years previously. However, improvements are needed for engaging all referred women and accessing women at an earlier gestation.

McCabe, J. E., & Arndt, S. (2012). Demographic and substance abuse trends among pregnant and non-pregnant women: Eleven years of treatment admission data. Maternal and Child Health Journal, 16(1), pp. 1696–1702 DOI: 10.1007/s10995-011-0872-z

The objective of this study was to identify demographic and substance abuse trends among pregnant women entering treatment over eleven years. This study compiled the publicly available Treatment Episode Datasets from the Substance Abuse Mental Health Services Administration from 1998 to 2008. Compared to non-pregnant women, pregnant women were more likely to be younger, minority, never married, less educated, homeless, and on public-assistance or have no income. Results show that a large proportion of pregnant women entering treatment are referred by the criminal justice system.

McGlade, A., Ware, R., & Crawford, M. (2009). Child protection outcomes for infants of substance-using mothers: A matched-cohort study. Pediatrics, 124(1), pp. 285-293.

In this study, the authors assessed differences in substantiated abuse between 2 groups of mothers in Brisbane, Australia to quantify this risk. Mothers who disclosed opiate, amphetamine, or methadone use between 2000 and 2003 were identified and compared with non-substance-using mothers. Participants were matched for gender and gestational age. All infants were linked to the Department of Child Safety Child Protection Information System database. Child protection outcomes, such as substantiated notifications and entry into foster care, were compared between groups. Results show that infants of substance-using mothers were more likely to suffer substantiated harm (hazard ratio 13.3 [95% confidence interval 4.6-38.3]) and to enter foster care (hazard ratio 13.3 [95% confidence interval 5.1-34.3]). Infants of mothers using illicit drugs were more likely to suffer substantiated harm and more likely to enter foster care than infants of mothers who were compliant with a methadone program. Infants of substance-using mothers have much poorer child protection outcomes than infants of non-substance-using mothers. This study adds substantial evidence toward a real association between maternal drug use and child abuse. Greater interagency collaboration is urgently required to reduce this risk.

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Metsch, L. R., Wolfe, H. P., Fewell, R., McCoy, C.B., Elwood, W.N., Wohler-Torres, B., et al. (2001). Treating substance-using women and their children in public housing: Preliminary evaluation findings. Child Welfare, 80(2), pp. 199-220.

Demonstration research and service programs have been initiated to verify that comprehensive, long-term residential treatment services for women will decrease alcohol and drug use, reduce reliance on social and health welfare programs, and improve functioning in specific life-skill and vocation areas. The article reports on one such program, SafePort, a residential substance abuse treatment program within public housing to provide drug treatment to parenting women. All family members-women, children, and significant others-receive comprehensive assessments to determine appropriate therapeutic interventions to resolve their problems. Preliminary evaluation findings suggest that women who participate with their children are more likely to remain drug free than are those who participated without their children. This model suggests that providing women and their children with a home as well as treatment for substance abuse and related issues facilitates women’s abstinence from drug use after treatment.

Meyer, M., Benvenuto, A., Howard, D., Johnston, A., Plante, D., Metayer, J., & Mandell, T. (2012). Development of a substance abuse program for opioid dependent nonurban pregnant women improves outcomes. Journal of Addiction Medicine, 6(2), pp. 124-130

This article provides results from a study aimed at determining if improved access to medication assisted therapy in the general population with improved coordination of ancillary services for pregnant women, improved perinatal outcomes in a nonurban area. Results show that improved access did improve perinatal outcomes and retention of maternal guardianship.

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Miller, K. M. (2014). Maternal criminal justice involvement and co-occurring mental health and substance abuse problems: Examining moderation of sex and race on children's mental health. Children and Youth Services Review, 37, pp. 71-80.

This study examines the extent that maternal mental health and substance abuse problems affect internalizing and externalizing behaviors among children dually exposed to child welfare and criminal justice systems. Results indicated that maternal risks were significantly associated with internalizing behaviors and that race was significantly associated with internalizing and externalizing behaviors. Sex and race moderated the associations between maternal risks and internalizing behaviors. Females exposed to maternal mental health and substance abuse problems exhibited elevated internalizing behaviors compared to males. Black children exposed to maternal substance abuse had decreased internalizing behaviors as compared to non-Black children.

Mitrani, V. B., Weiss-Laxer, N., & Feaster, D. J. (2009). Factors related to loss of child custody in HIV+ women in drug abuse recovery. American Journal of Drug & Alcohol Abuse, 35(5), pp. 320-324. DOI: 10.1080/00952990903060143

This study explores factors associated with child custody loss among HIV+ women in drug abuse recovery, and compares mothers who have custody of their children to mothers who do not have custody of all of their children. The results of the study reflect that the lost-custody group was less likely to be employed and had more history of violent impulses and arrest, particularly on drug charges. The groups reported similar recent and lifetime drug use patterns, but the custody group had received more drug treatment. Post-hoc analyses found the lost-custody group had lower rates of participation in the interventions offered in the parent clinical trial and higher avoidant coping. The sample in the current study supports that HIV+ women in drug recovery are at high risk of loss of child custody. Non-adherence to available treatment seems to be associated with loss of child custody. Scientific significance: Results suggest the need for further research and active treatment outreach for this population.

Niccols, A., Milligan, K., Smith, A., Sword, W., Thabane, L. & Henderson, J. (2012). Integrated programs for mothers with substance abuse issues and their children: A systematic review of studies reporting on child outcomes. Child Abuse & Neglect, 36(4), pp. 308-322.

The goal of this study was to examine the impact and effects of integrated programs for women with substance abuse issues and their children using a review of studies published from 1990 to 2011. Based on the authors literature review, evidence supports integrated programs, suggesting that they are associated with improvements in child development, growth, and emotional and behavioral functioning. More research is required comparing integrated to non-integrated programs. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the needs of children of women with substance abuse issues.

O’Brien, L. P. (2014). Performance measurement: A proposal to increase use of SBIRT and decrease alcohol consumption during pregnancy. Maternal Child Health Journal, 18(1), pp. 1-9. DOI: 10.1007/s10995-013-1257-2.

This article aims to address the guidelines recommending SBIRT for pregnant women, appropriate screening instruments, the evidence regarding implementation of SBIRT for pregnant women, and existing performance measures. The authors recommend that clinicians should use universal SBIRT for all pregnant women, claiming that the universal application of the screening tool will reduce disparities in screening and consequences. The results of the SBIRT should also be taken seriously, and advocate for intervention and subsequent booster sessions, and carefully coordinated referral and follow-up to make a difference.

O'Connor, M. J., & Whaley, S. E. (2006). Health care provider advice and risk factors associated with alcohol consumption following pregnancy recognition. Journal of Studies on Alcohol, 67(1), pp. 22-31.

This study examined the extent to which pregnant women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were counseled by their health care providers to stop drinking alcohol during pregnancy. A second purpose was to identify characteristics associated with alcohol consumption post recognition of pregnancy. Sixty percent of sample women had been advised by their care providers not to drink alcohol during pregnancy. Women who were most likely to receive advice were black non-Hispanic and Hispanic, were Spanish speaking, were less educated, were on public assistance, and had a higher number of alcohol-related risk behaviors. Advanced age, public assistance, caffeine use, smoking, and elevated TWEAK and CES-D scores predicted elevations in alcohol consumption rates. The authors concluded that although advice to stop drinking during pregnancy was provided to 60% of this sample, women continued to drink following pregnancy recognition, with alcohol consumption rates highly associated with sociodemographic and psychological factors, namely maternal depression. Because elevations in alcohol consumption during pregnancy are associated with poorer developmental outcomes for children, further efforts are needed to better address social and mental health factors that influence consumption.

Oei, J. L., Kingsbury, A., Dhawan, A., Burns, L., Feller, J. M., Clews, S., Falconer, J., & Abdel-Latif, M. E (2012). Amphetamines, the pregnant woman and her children: a review. Journal of Perinatology, 32(10), pp. 737-747.

This study reviews and summarizes available evidence regarding the impact of amphetamines on pregnancy, the newborn infant and the child. Based on the reviews, the authors suggest that exposed children may be at risk of ongoing developmental and behavioral impediment, and recommend that efforts aim to improve early detection of perinatal exposure and to increase provision of early-intervention services for affected children and their families.

Olsen, A., Banwell, C., & Madden, A. (2014). Contraception, punishment and women who use drugs. BMC Women’s Health, 14(1), pp. 5.

This article provides an in-depth look at contraceptive use, pregnancy and mothering by Australian women with a history of injecting drug use. The authors argue that health programs which aim to reduce barriers to free, non-discriminating reproductive advice and parenting assistance would be best for this population. Women's drug use should not automatically be associated with an inability to make informed health care choices or to care for children. Evidence suggests that women who use drugs do not need to be paid to limit or end their fertility.

Ondersma, S. J., Winhusen, T., Erickson, S. J., Stine, S. M., & Wang, Y. (2009). Motivation enhancement therapy with pregnant substance-abusing women: Does baseline motivation moderate efficacy? Drug & Alcohol Dependence, 101(1), pp. 74-79.

The present study was conducted to examine whether disordinal moderation by baseline motivation could partially explain negative findings in a previous study [Winhusen, T., Kropp, F., Babcock, D., Hague, D., Erickson, S.J., Renz, C., Rau, L., Lewis, D., Leimberger, J., Somoza, E., 2008). Analyses also focused on the relative utility of the University of Rhode Island Change Assessment (URICA) scale, vs. a single goal question as potential moderators of Motivation Enhancement Therapy (MET). Participants were 200 pregnant women presenting for substance abuse treatment at one of four sites. Women were randomly assigned to either a three-session MET condition or treatment as usual (TAU). Generalized Estimating Equations (GEE) revealed no significant moderation effects on drug use at post-treatment. At follow-up, contrary to expectations, participants who had not set a clear quit goal at baseline were less likely to be drug-free if randomized to MET (OR=0.48); participants who did set a clear quit goal were more likely to be drug-free if randomized to MET (OR=2.53). No moderating effects were identified via the URICA. Disordinal moderation of MET efficacy by baseline motivation may have contributed somewhat to the negative results of the study, but in the opposite direction expected. A simple question regarding intent to quit may be useful in identifying persons who may differentially respond to motivational interventions. However, moderation effects are unstable, may be best identified with alternate methodologies, and may operate differently among pregnant women.

Ondersma, S. J., Svikis, D. S., Thacker, L. R., Beatty, J. R., & Lockhart, N. (2014). Computer-delivered screening and brief intervention (e-SBI) for postpartum drug use: A randomized trial. Journal of Substance Abuse Treatment, 46(1), pp. 52-59.

This article presents the results of a study designed to replicate previous findings from a single 20-minute e-SBI for drug use among postpartum women. A total of 143 postpartum, primarily low-income African-American women meeting criteria for drug use, were randomly assigned to either a tailored e-SBI or a time-matched control condition. Additional primary outcomes suggested small to moderate effect sizes in favor of the e-SBI, but did not reach significance. This result replicates previous findings but fails to show durable effects. Assessment reactivity, e-SBI design, and possible extension of e-SBI via tailored messaging all merit careful consideration.

Oral, R., Koc, F., Bayman, E. O., Assad, A., Austin, A., Strang, T., & Bayman, L. (2012). Perinatal illicit drug screening practices in mother-newborn dyads at a university hospital serving rural/semi-urban communities: translation of research to quality improvement. The Journal of Maternal-Fetal and Neonatal Medicine, 25(11), pp. 2441–2446. DOI: 10.3109/14767058.2012.703714

The purpose of this study is to determine 1) documentation practices among relevant health care professionals to determine if they are documenting risk factors listed in the protocol; 2) prevalence of risk factors of mother/infant dyads admitted for delivery and; 3) prevalence of dyads not tested who present with risk factors indicating a need for testing. Results of this study reflect that some infants who need to be tested were missed during the pregnancy period. The data in the present study revealed the necessity of a staff-training program and the revision of the hospital perinatal illicit drug screening practices- intervention.

Pajulo, M., Pyykkonen, N., Kalland, M., Sinkkonen, J., Helenius, H., Punamaki, R., & Suchman, N. (2012). Substance-abusing mothers in residential treatment with their babies: Importance of pre- and postnatal maternal reflective functioning. Infant Mental Health Journal, 33(1), pp. 70-81. DOI: 10.1002/imhj.20342

The aims of the study are to explore maternal pre- and postnatal reflective functioning and its association with background factors, maternal exposure to trauma, and psychiatric symptoms, postnatal interaction, child development, and later child foster care placement. Increase in Reflective Functioning level was found to be associated with type of abused substance and maternal trauma history. Results show that mothers who showed lower postnatal RF levels were more likely to relapse after completing a residential treatment period, with their children more likely to be placed in foster care. The intensive focus on maternal RF is an important direction in the development of efficacious treatment for this very high risk population.

Perreira, K. M., & Cortes, K. E. (2006). Race/ethnicity and nativity differences in alcohol and tobacco use during pregnancy. American Journal of Public Health, 96(9), pp. 1629-1636.

The authors examined race/ethnicity and nativity correlates of prenatal substance use. Using data on a nationally representative cohort of pregnant women in US cities (N = 4185), the authors evaluated the relative importance of socioeconomic status, paternal health behaviors, social support, and maternal stress and health history in explaining variations in prenatal substance use by race/ethnicity and nativity. The authors found that maternal stress and health history appeared to fully explain differences in alcohol use by nativity, but these and other factors could not explain differences in prenatal smoking. The authors concluded that foreign-born immigrant women are at equal risk of prenatal alcohol use compared with similarly situated US-born women and should not be overlooked in the design of interventions for at-risk women. Furthermore, the inclusion of fathers and the development of social support structures for at-risk women can strengthen interventions.

Prasad, M. (2014). When opiate abuse complicates pregnancy. Contemporary OBGYN, pp. 28.

This article presents background information on opiate use during pregnancy and provides information on how to best intervene in these situations that will most benefit mother and baby. The authors argue that early prevention, appropriate screening, brief intervention and referral to treatment are the best options for intervention.

Pregnancy-related drinking reduction varies between white, black women. (2008). DATA: The Brown University Digest of Addiction Theory & Application, 27(10), pp. 3-4.

The article presents a study on the pregnancy-related changes in alcohol consumption between Black and White women. Daniel S. Morris and colleagues found that White women appear more likely to reduce drinking and binge drinking upon becoming pregnant than Black women. Other predictors of differences in drinking levels include age, education and smoking. Authors highlight the need for alcohol education programs and interventions for pregnant drinkers in the Black community.

Reid, C., Greaves, L., & Poole, N. (2008). Good, bad, thwarted or addicted? Discourses of substance-using mothers. Critical Social Policy, 28(2), pp. 211-234.

This paper examined discourses of mothers who use substances. Focus groups were conducted at two different treatment programs with diverse women who identified as mothers challenged by substance use. Through the use of three lenses - rights, risks, and evidence - we identified four major discourses in the participants' talk. The 'good mother', 'bad mother', 'thwarted mother' and 'addicted mother' discourses revealed the multiple and at times contradictory ways the women made sense of their lives. Within all of the discourses the mother-child bond and the importance of providing necessary supports to mothers with substance-use problems were central. The women's discourses highlighted the challenges of negotiating the prevailing attitudes, practices and stigmas of being a substance-using mother while trying to do the right thing for their children.

Roberts, S. C., & Pies, C. (2011). Complex calculations: How drug use during pregnancy becomes a barrier to prenatal care. Maternal Child Health Journal, 15(3), pp. 333-41. DOI: 10.1007/s10995-010-0594-7

This study sought to understand how drug use and factors associated with drug use influence women’s prenatal care use. According to the authors, women using drugs attend and avoid prenatal care for reasons not connected to their drug use: concern for the health of their baby, social support, and extrinsic barriers such as health insurance and transportation. Drug use itself is a barrier for a few women. Increasing the number of pregnant women who use drugs who receive prenatal care requires systems-level rather than only individual-level changes. These changes require a paradigm shift to viewing drug use in context of the person and society and acceptance of responsibility for unintended consequences of public health bureaucratic procedures and messages about effects of drug use during pregnancy.

Sarkola, T., H. Kahila, et al. (2007). Risk factors for out-of-home custody child care among families with alcohol and substance abuse problems. Acta Paediatrica, 96(11), pp. 1571-6

The aim of this study was to look at the risk of children to mothers with alcohol and/or substance abuse related problems for early childhood out-of-home care in Finland. According to the authors, out-of-home care was associated with maternal care for substance abuse after delivery, non-employment, housing, daily smoking during pregnancy, increasing number of previous births, mother in custody in her childhood, maternal education, previous child in custody, drug in urine during pregnancy, unplanned pregnancy, partner with significant abuse, regular health-care contact for abuse, daily alcohol consumption before and/or during pregnancy, newborn not discharged with mother, neonatal abstinence symptoms (NAS), intensified perinatal surveillance or NICU, and delayed discharge from hospital. Conclusions: There is a substantial risk of children born to mothers with significant alcohol and/or substance abuse related problems for out-of-home care during early childhood. Factors identified during the pre- and perinatal period are associated with this risk.

Schilling, R., Mares, A., & El-Bassel, N. (2004). Women in detoxification: Loss of guardianship of their children. Children and Youth Services Review, 26(5), pp. 463-480.

This study depicts the living circumstances of children of women in detoxification for heroin or crack cocaine. The study also found that women who did not live in their own home, had less education and used multiple drugs were more likely to have lost guardianship of one or more children. Study findings expand understanding of the detrimental effects of parental drug abuse on children's life opportunities.

Sharpe, T. T., & Velasquez, M. M. (2008). Risk of alcohol-exposed pregnancies among low-income, illicit drug-using women. Journal of Women's Health, 17(8), pp. 1339-1344.

This article presents the findings of a survey administered to 2672 women 18–44 years of age in settings serving low-income women, including an urban jail, a drug treatment facility, and healthcare facilities in Florida, Virginia, and Texas. Results showed that of the women interviewed, 75% (2000) reported using more than one illicit drug. Drug users were more likely to report frequent drinking, binge drinking, and drinking during compared with nonusers. Greater proportions of drug users also failed to use contraception compared with nonusers. Notable proportions of both groups, drug users (91%) and nonusers (82%), reported unplanned pregnancies. The findings suggest that poor women who reported ever using more than one illicit drug were at greater risk for having an alcohol-exposed pregnancy. Unplanned pregnancies in both groups surpassed national averages. Poor women likely require enhanced education about the hazards of drinking during pregnancy and methods to reduce unplanned pregnancies.

Simmons, L. A., Havens, J. R., Whiting, J. B., Holz, J. L., & Bada, H. (2009). Illicit drug use among women with children in the United States: 2002–2003. Annals of Epidemiology, 19(3), pp. 187-193.

This article draws on data from the 2002 and 2003 National Survey on Drug Use and Health, a nationally representative sample of the U.S. civilian population. The current analysis utilized a subsample of women (N =19,300) who reported having children younger than 18 years in the home. Past year abuse or dependence on cocaine, heroin, marijuana, stimulants, and hallucinogens as well as nonmedical use of prescription medications were assessed. According to the authors, prevention and intervention strategies should focus on developing and testing methods to screen for both risk factors associated with maternal drug abuse and actual substance abuse in primary and emergency care settings to reduce youth exposure and improve child developmental outcomes.

Slesnick, N., Feng, X., Brakenhoff, B., & Brigham, G. S. (2014). Parenting under the influence: the effects of opioids, alcohol and cocaine on mother-child interaction. Addictive Behaviors, 39(1), pp. 897-900.

This article presents the findings of a study looking at the parenting and mother-child interaction among mothers with different drugs of choice or among mothers of older children, between 8 and 16 years. The authors’ findings suggest that substance using mothers have less undermining autonomy and higher mother maternal acceptance. African American mothers in the study were observed to have fewer negative interactional behaviors than Whites and both mothers and children reported higher firm control and maternal acceptance.

Stein, J. A., & Koniak-Griffin, D. (2010). Latent growth trajectories of substance use among pregnant and parenting adolescents. Psychology of Addictive Behaviors, 4(2), pp. 322-332.

In this study, the authors examine changes among adolescent girls in substance use during pregnancy and the postpartum period. This is a secondary analysis of data from a sample of 305 ethnic minority females (245 Latina, 60 African American), aged 13–18 years, who were pregnant at baseline and were participating in an HIV prevention study conducted in inner-city alternative schools in Los Angeles County. Data collected at 4 time points captured changes in substance use from pregnancy through the postpartum period. Baseline predictors included ethnicity/race, partner substance use, childhood abuse history, religiosity, acculturation, depressive symptoms, length of gestation at baseline, and previous substance use. Common predictors of greater resumption and/or greater level of use included greater history of use before pregnancy, partner substance use, childhood abuse, and a longer time since childbirth. African Americans were more likely to be smoking at baseline when they were still pregnant and to use marijuana postpartum; Latinas were more likely to use alcohol over the course of pregnancy and postpartum. Findings may assist prenatal care providers to identify and counsel pregnant adolescents at risk for perinatal substance use and to prevent resumption or initiation of substance use after childbirth.

Suchman, N., DeCoste, C., Castiglioni, N., McMahon, T. J., Rounsaville, B., & Mayes, L. (2010). The mothers and toddlers program, an attachment-based parenting intervention for substance using women: Post-treatment results from a randomized clinical pilot. Attachment & Human Development, 12(5), pp. 483-504.

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

Suchman, N. E., DeCoste, C., Leigh, D., & Borelli, J. (2010). Reflective functioning in mothers with drug use disorders: Implications for dyadic interactions with infants and toddlers. Attachment & Human Development, 12(6), 567-585.

In this study, we examined maternal reflective functioning as a bi-dimensional construct in a sample of 47 mothers with drug use disorders caring for infants and toddlers. We first tested a two-factor solution with scale items from the Parent Development Interview and confirmed the presence of two related but distinct dimensions: self-mentalization and child-mentalization. We then tested predictions that (a) self-mentalization would be associated with overall quality of maternal caregiving and that (b) child-mentalization would be associated with (i) maternal contingent behavior and (ii) child communication. Results partially supported hypotheses (a) and (bii). Unexpectedly, self-mentalization alone was associated with maternal contingent behavior. Findings suggest that self-mentalization may be a critical first step in improving mother-child relations involving mothers with drug use disorders. Implications for theory and practice are discussed.

Suchman, N., 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), pp. 179-185.

Mothers who are physically and/or psychologically dependent upon alcohol and illicit drugs are at risk for a wide range of parenting deficits beginning when their children are infants and continuing as their children move through school-age and adolescent years. Behavioral parent training programs for drug-dependent mothers have had limited success in improving parent-child relationships or children’s psychological adjustment. One reason behavioral parenting programs may have had limited success is the lack of attention to the emotional quality of the parent-child relationship. Research on attachment suggests that the emotional quality of mother-child relationships is an important predictor of children’s psychological development through school-age and adolescent years. In this paper, the authors present a rationale and approach for developing attachment-based parenting interventions for drug-dependent mothers and report preliminary data on the feasibility of offering an attachment-based parenting intervention in an outpatient drug treatment program for women.

Suchman, N., Pajulo, M., DeCoste, C., & Mayes, L. (2006). Parenting interventions for drug-dependent mothers and their young children: The case for an attachment-based approach. Family Relations, 55(2), pp. 211-226.

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

Suchman, N. E., McMahon, T. J., Zhang, H., Mayes, L. C., & Luthar, S. (2006). Substance-abusing mothers and disruptions in child custody: An attachment perspective. Journal of Substance Abuse Treatment, 30(3), pp. 197-204.

Using an attachment framework, the authors examined the following; (1) whether substance-abusing mothers' perceptions of how they were parented were related to the severity of their substance abuse and psychological maladjustment and (2) whether these two factors mediated the association between mothers' perceptions of how they were parented and their children's placement out of home. The authors found that out-of-home placement of substance-abusing children appeared to be linked with risks at multiple levels of influence (e.g., sociodemographic, family/social, individual maternal adjustment, and child characteristics). In addition, mothers who perceived their own mothers as uncaring and intrusive were more likely to have developed severe substance abuse problems and psychological maladjustment and to have lost custody of a minor child. The authors suggest that the findings are consistent with an attachment perspective on parenting suggesting that the internal psychological processes of a parent play a critical role in the continuity of parenting.

Sun, A-P. (2004). Principles for practice with substance-abusing pregnant women: A framework based on the five social work intervention roles. Social Work, 49(3), pp. 383-394.

The author discusses components essential to pregnancy-specific substance abuse treatment, based on a review of the literature. Elements and issues related to substance abuse during pregnancy are identified under the five social work intervention roles: teacher, broker, clinician, mediator, and advocate. These five roles are used as a framework and integrate relevant literature. The concepts and approaches presented in this article can be applied by social workers in residential or outpatient substance abuse treatment programs; hospital prenatal, labor, and delivery units; the child welfare system; public health districts; or community family service centers.

Taplin, S., & Mattick, R. P. (2013). Mothers in methadone treatment and their involvement with the child protection system: a replication and extension study. Child Abuse & Neglect, 37(1), pp. 500-510.

This article presents the findings of a study in which mothers involved with child protection were interviewed about their histories. Findings reflect that factors which increased the likelihood of involvement with child protective services were: 1) having greater number of children; 2) being on psychiatric medication; and 3) having less than daily contact with her own parents.

Tenkku, L., Morris, D., Salas, J., & Xaverius, P. (2009). Racial disparities in pregnancy-related drinking reduction. Maternal & Child Health Journal, 13(5), pp. 604-613. DOI: 10.1007/s10995-008-0409-2

The purpose of this study was to investigate the likelihood that women of different racial and ethnic groups would reduce their alcohol consumption during pregnancy. Results reflected that, Black, Asian/Pacific Islander and Hispanic women were all significantly less likely than White women to reduce their heavy drinking after becoming pregnant. American Indian/Alaskan Native women who were moderate drinkers before conception were over 2 times more likely than White women to reduce drinking after becoming pregnant, although this difference was non-significant. Among those who binge drank in the months before pregnancy, compared to White women, Black, Hispanic, American Indian/Alaskan Native, and Asian/Pacific Islander women were all less likely to quit binge drinking while pregnant. The authors conclude that significant racial differences in pregnancy-related drinking reduction are evident, and may help explain racial disparities in FAS. Results suggest that more targeted efforts are needed to meet the national goals of preventing alcohol-exposed pregnancies.

Thompson, E. L., Thompson, L. A., Black, E. W., Esernio-Jenssen, D., Hardt, N., Das, R., & Roth, J. (2013). Identifying indicators during pregnancy for child maltreatment. Maternal and Child Health Journal, 17(1), pp. 1817-1824.

This article presents findings of a study which looked at interpregnancy interval (IPI) as a predictor of later report of child maltreatment. Findings of the study suggest that an API of less than 18 months was associated with higher odds of maltreatment compared to API greater than 18 months.

Serane, V. T., & Kurian, O. (2012). Neonatal abstinence syndrome. Indian Journal of Pediatrics, 75(1), pp. 911.

This article presents the findings of a study on substance misuse in pregnant mothers and its impact on their newborns. According to the findings, the majority of the infants born to mothers on methadone exhibited NAS and required pharmacological treatment.

Velez, M. L., Jansson, L. M., Montoya, I. D., Schweitzer, W., Golden, A., & Svikis, D. (2004). Parenting knowledge among substance abusing women in treatment. Journal of Substance Abuse Treatment, 27(3), pp. 215-222.

The purpose of this study was to assess parenting knowledge and beliefs among drug abusing pregnant and recently postpartum women engaged in a comprehensive substance abuse treatment program. This study examined the effects of a parenting skills training program incorporated into a maternal substance abuse treatment program. Findings demonstrated that parenting skills training, as a component of drug treatment, was associated with at least short-term improvements in parenting knowledge. Parenting knowledge and practices are particularly important for this group of women, as their children are at high risk for developmental and other difficulties. Systematic evaluation of parenting knowledge among women of childbearing age entering substance abuse treatment is recommended. Substance abuse treatment for drug-dependent pregnant and postpartum women should include a parenting skills training component with the ultimate goal of improving the overall development of the drug-exposed child.

Winhusen, T., Kropp, F., Babcock, D., Hague, D., Erickson, S. J., Renz, C., et al. (2008). Motivational enhancement therapy to improve treatment utilization and outcome in pregnant substance users. Journal of Substance Abuse Treatment, 35(2), pp. 161-173.

This study looks at how pregnant substance users can benefit significantly from substance abuse treatment, and improve treatment retention. Two hundred pregnant substance users entering outpatient substance abuse treatment at one of four treatment programs were randomized to receive either three individual sessions of Motivational Enhancement Therapy for pregnant substance users (MET-PS) or the first three individual sessions normally provided by the program. All participants were encouraged to participate in all other treatment offered by the program. Outcome measures included treatment utilization according to clinic records, qualitative urine toxicology measures, and self-report of substance use. One hundred sixty-two (81%) participants completed the 1-month active phase. Participants attended 62% of scheduled treatment on average and reported decreased substance use during the first month of treatment, with no differences between MET-PS and treatment-as-usual (TAU) participants. There was some evidence that the efficacy of MET-PS varied between sites and that MET-PS might be more beneficial than TAU in decreasing substance use in minority participants. These results suggest that MET-PS is not more effective than TAU for pregnant substance users in general but that there might be particular subgroups or treatment programs for which MET-PS might be more or less effective than TAU.

Winklbaur, B., Kopf, N., Ebner, N., Jung, E., Thau, K., & Fischer, G. (2008). Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. Addiction, 103(9), pp. 1429-1440.

The authors of this article derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants. The authors believe pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication.

Yonkers, K. A., Howell, H. B., Allen, A. E., Ball, S. A., Pantalon, M. V., & Rounsaville, B. J. (2009). A treatment for substance abusing pregnant women. Archives of Women's Mental Health, 12(4), pp. 221-227.

The authors describe the adaptation of a manualized behavioral treatment for substance using pregnant women that includes components of motivational interviewing and cognitive therapy. Therapy was administered concurrent with routine prenatal care at inner-city maternal health clinics in New Haven and Bridgeport, Connecticut, small urban cities in the USA. Substance use was monitored by self-report, and urine and breath tests. Treatment fidelity was assessed using the Yale Adherence and Competence System. Behavioral treatment delivery in this setting is feasible and is being evaluated in a randomized, controlled, clinical trial.

Young, J. L., & Martin, P. R. (2012). Treatment of opioid dependence in the setting of pregnancy. Psychiatric Clinics of North America, 35(1), pp. 441-460.

This article gives brief background information on opioid dependence during pregnancy. The authors argue that treatment plans for pregnant women with opioid dependence must consider psychiatric and medical options, as well as buprenorphine, but more research is needed. According to the authors, methadone treatment remains the standard of care for treatment in pregnancy.

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