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Niccols A., Milligan K., Sword W. et al.
Harm Reduction Journal: 2012, 9:14.
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The first systematic review of whether integrated substance use/parenting programmes improve the parenting of problem substance using mothers found remarkably few quality studies, but enough to suggest that such programmes can improve the prospects of often highly at-risk children.
Summary Treatment for mothers with substance use problems may be an important opportunity to improve parenting and break the intergenerational cycle of addiction and dysfunction. However, such women find it difficult to use conventional systems of care (for reasons including fear of losing custody of children, guilt, stigma, and lack of transportation), and prefer comprehensive services provided in a caring, 'one-stop' setting. Researchers, clinicians, and policymakers also recommend that substance use treatment programmes address women's needs and those of their children through comprehensive, integrated services at the same site.
The result has been the development of numerous programmes integrating addiction treatment with on-site pregnancy, parenting, or child-related services. Typically these provide individual addiction treatment, maternal mental health services, trauma treatment, parenting education and counselling, life skills training, prenatal education, medical and nutrition services, education and employment assistance, child care, children's services, and aftercare.
However, no review has yet systematically assessed the impact of these programmes on the quality of parenting. The featured review aimed to fill this gap, specifically by seeking evidence on whether integrated programmes are more effective than usual addiction treatment, and whether some features of integrated programmes are associated with better parenting outcomes than others.
The analysts searched databases for studies published in English from 1990 to May 2011 and conducted other searches to ensure as far as possible that all relevant studies were identified. Of the 31 studies which reported on the quality of parenting, just four were randomised trials; three involved mothers with children and one pregnant women. The women averaged 29–36 years of age. Most had experienced trauma and mental health problems, and were unemployed, single mothers. The children ranged from infants to adolescents. Programmes lasted three to 12 months and had a high dropout rate.
Three of the trials addressed whether integrated programmes improve parenting more than usual addiction treatment by randomly allocating women and their children to one or the other. One assessed the involvement of the children with child protection services and found no differences attributable to integrated residential or outpatient programmes versus usual outpatient substance use treatment. The other two studies used standard interviews or questionnaires to assess the quality of parenting and/or the child-parent relationship as reported by the mother. Both involved methadone patients offered standard treatment (in one case plus recovery training) versus this plus group maternal psychotherapy. On a variety of measures they found typically small extra parenting improvements among mothers assigned to the psychotherapy.
The issue of whether some types of integrated programmes are more effective than others was addressed by examining all 31 studies with parenting outcome data, most of which simply assessed mothers in integrated programmes without comparing them with equivalent mothers not offered integrated treatment. Across these residential programmes seemed more effective than non-residential, and programmes which included a maternal mental health service more effective than those which did not.
One study randomly assigned mothers (of children under three) in outpatient substance abuse treatment to an attachment-based parenting intervention, or a parenting programme featuring case management and child guidance pamphlets. Immediately after these three-month programmes the attachment-based option had led to slightly greater improvements on some parenting measures, which six weeks later were no longer statistically significant.
In one study, as during treatment mothers became less depressed their parenting scores improved; in another, when their children had stayed with them in a residential facility, mothers were five times more likely to have custody of their children at the end of treatment.
From the few randomised trials it seems that compared to usual addiction treatment, integrated programmes lead to small extra improvements in parenting. The one trial to assess involvement with child protection services found no differences, and no randomised comparisons assessed parenting attitudes, knowledge, or whether mothers retained or regained custody of their children. In three studies parenting improvements were associated respectively with an attachment-based parenting intervention, children residing in the treatment facility, and improvements in maternal mental health.
Even if the advantage of integrated programmes is small, this could have a large impact on the associated financial and human burden in this vulnerable population, for example by reducing the need for foster care, treatment of the child, psychiatric admissions, or by reducing crime.
A weakness of the randomised trials was that none directly observed the mother's parenting, perhaps a more objective and valid method than the mother's own accounts. Also, the studies comparing integrated to usual treatment did not assess some important areas of maternal functioning possibly impacted by substance use, such as maternal responsiveness, sensitivity, and reflective functioning, nor did they assess cost-effectiveness.
commentary Given the importance of the issue, this was a remarkably sparse and weak set of studies, partly because of the restriction to mothers. It meant, for example, the exclusion of an important Australian study of methadone treatment patients caring for children; most but not all were mothers. On all the measures of parenting, child welfare risk, and child behaviour, patients allocated to a specially designed programme involving ten home visits over three months had improved substantially, while generally the others had not.
This study however was unable to tell whether the improvements were simply due to adding an extra intensive intervention, or due specifically to the parenting focus. Relevant to this issue, the featured review included two studies of methadone patients offered standard treatment or this plus recovery training, versus standard treatment plus group maternal psychotherapy. Where the same measures were used, the impacts of maternal psychotherapy seem to have been far greater compared to usual treatment rather than this plus recovery training, suggesting that doing something extra which was therapeutic was at least as much of an active major ingredient as focusing on parenting.
Partially set against this is the study cited in the review (1 2) which equalised the time mothers were offered in two forms of parenting interventions, one focused on emotions and attachment and the relationship with the child, the other on accessing external services (a 'case management' approach) and parenting education. The former generally led to greater improvements, but some were slight and with a small sample, few were statistically significant. These results do however suggest that content can matter, and perhaps too where services are provided (see below).
The studies found by the featured review leave us almost entirely in the dark on whether offering parenting support on-site as one of (as far as the patient is concerned) the services provided by the substance use treatment agency is preferable to referring patients to external support. Perhaps the critical factor will be the patients' feeling of safety at a familiar service not directly linked to statutory child protection, likely to increase the chances that they will admit to being in need of support and accept it. Another factor is the inevitable degree of attrition when patients are required to make another appointment and go somewhere else for services; even the willing will sometimes not get there. At US methadone treatment services just 10% of the children of patients who had aroused concern completed child development assessments off-site, but 85% when the assessment team visited the clinics and appointments were arranged to coincide with the patient's supervised consumption visit to the clinic. These considerations could be why (see previous paragraph) a case management approach to parenting support has been found less effective than direct on-site provision.
While the featured review uses the label 'integrated', the programmes it evaluated seem best described as on-site add-ons to substance use treatment rather than integrated with it in the manner of some programmes for mentally ill substance users, when the substance use treatment and the psychiatric components are both adjusted to the patient's condition and to each other.
The population addressed by the featured review – problem substance using parents – are a major concern for the UK where well over a million children have parents with a drug or alcohol problem. Across the UK, national targets, service standards and policy statements have embodied the perspective that their welfare is a core concern for services in contact with problem drug users, a contention featuring strongly in the latest Scottish and English drug strategies. In England it formed a specific workstream of the National Treatment Agency for Substance Misuse (NTA), which produced guidance on how authorities responsible for drug and alcohol services can work more closely with children and family services. In 2010 Scotland produced new child protection guidance which more fully addressed the issue of children affected by parental substance misuse.
For more see this Findings hot topic.
Thanks for their comments on this entry in draft to research author Alison Niccols of McMaster University in Canada. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 10 August 2013. First uploaded 22 July 2013
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STUDY 2008 Final report on the evaluation of 'Option 2'