Neonatal outcomes of pregnant women attending integrated and standard substance use treatment programs in Ontario, Canada.

BACKGROUND: Substance use in pregnancy raises concern given its potential teratogenic effects. Given the unique needs of parenting people and the potential impact for developing children, specialized substance use treatment programs are increasingly being implemented for this population. Substance use treatment is associated with more positive neonatal outcomes compared with no treatment, however treatment models vary limiting our understanding of key treatment components/modelsFew studies have explored the influence of treatment model type (i.e., integrated treatments designed for pregnant clients compared with standard treatment models) and no studies have examined the influence of treatment model on neonatal outcomes using Canadian data. METHOD: We conducted a population-based cohort study of clients who were pregnant when initiating integrated (n = 564) and standard (n = 320) substance use treatment programs in Ontario, Canada. RESULTS: Neonatal outcomes did not significantly differ by treatment type (integrated or standard), with rates of adverse neonatal outcomes higher than published rates for the general population, despite receipt of adequate levels of prenatal care. While this suggests no significant impact of treatment, it is notable that as a group, clients engaged in integrated treatment presented with more risk factors for adverse neonatal outcomes than those in standard treatment. While we controlled for these risks in our analyses, this may have obscured their influence in relation to treatment type. CONCLUSION: Findings underscore the need for more nuanced research that considers the influence of client factors in interaction with treatment type. Pregnant clients engaged in any form of substance use treatment are at higher risk of having children who experience adverse neonatal outcomes. This underscores the urgent need for further investment in services and research to support maternal and neonatal health before and during pregnancy, as well as long-term service models that support women and children beyond the perinatal and early childhood periods.

Specifying the Relations among PTSD Symptom Clusters and Parenting Stress in Mothers Engaged in Substance Use Treatment.

INTRODUCTION: Parenting stress is often heightened in mothers receiving treatment for substance use. Experiences of trauma are commonly seen in this population, which may give rise to Posttraumatic Stress Disorder (PTSD) symptoms, including intrusion, avoidance, negative cognition and mood, and affective arousal. While past research has demonstrated a significant relation between PTSD symptoms and parenting stress, no studies have examined the relative contributions of these symptoms to parenting stress in mothers engaged in substance use treatment. METHODS: Seventy-four mothers attending outpatient substance use treatment who were parenting children aged 0-3 years completed measures of parenting stress, PTSD, substance use, and depression symptoms. RESULTS: A canonical correlation analysis indicated two canonical variates accounting for significant variance between PTSD symptom clusters and parenting stress measures. The first canonical variate, primarily reflecting depressive and PTSD cognition and mood symptoms, was predominantly related to the parental distress aspect of parenting stress (40%). The second canonical variate, primarily reflecting intrusion and avoidance PTSD symptoms, was associated with increased parental perceptions of their child as difficult (10%). CONCLUSION: Future research directions and clinical implications of these results are discussed for designing parenting interventions with mothers attending substance use treatment who present with PTSD symptoms.

Caring for children with mental health or developmental and behavioural disorders: Perspectives of family health teams on roles and barriers to care.

OBJECTIVE: To inform a shared care model between developmental and behavioural (DB) and mental health specialists and primary care physicians by having members of primary care family health teams (FHTs) report on strengths of and barriers to providing care for children with DB disorders and mental health concerns. DESIGN: Qualitative study using semistructured focus groups. SETTING: Academic and community-based FHTs in Toronto, Ont. PARTICIPANTS: Primary care physicians, nurses, allied health professionals, and family medicine trainees within the participating FHTs. METHODS: Nine focus groups were conducted with FHT members, and transcripts were analyzed for key themes using an inductive thematic analysis approach. MAIN FINDINGS: Eighty-four participants across 9 sites were interviewed. Six sites were academically affiliated and 3 were community based. Participants described their roles in the care of children with DB disorders as primarily "referral agent" but also as "long-term supporter" and "health care coordinator." Family health team members expressed the desire to "learn" and "do more" for these children but noted numerous barriers to providing care, captured in 4 overarching themes: limited training beyond how to screen, lack of service knowledge, limited time and communication, and cumbersome access to mental health and dual diagnosis services. CONCLUSION: Primary care physicians are in the unique position of being able to provide longitudinal care for children with DB and mental health disorders. However, they perceive barriers to providing care that can affect access to services, service quality, and health outcomes for these children and their families. The health system might benefit from addressing these barriers by providing more training for primary care physicians in the longitudinal care of children with mental health and DB disorders, and by improving communication between FHTs and DB and mental health specialists regarding service navigation and emerging comorbidities. A shared care model integrating DB and mental health specialists into primary care might be one approach that warrants implementation and research.

Levels and predictors of participation in integrated treatment programs for pregnant and parenting women with problematic substance use.

BACKGROUND: Women who are seeking services for problematic substance use are often also balancing responsibilities of motherhood. Integrated treatment programs were developed to address the diverse needs of women, by offering a holistic and comprehensive mix of services that are trauma- and violence-informed, and focus on maternal and child health promotion and the development of healthy relationships. METHODS: Using system-level administrative data from a suite of outpatient integrated programs in Ontario, Canada, we described the clients and rates and predictors of treatment participation over a 7-year period (2008-2014; N = 5162). RESULTS: All participants were either pregnant or parenting children under 6 years old at admission to treatment. Retention (length of time between the first and last visit) averaged 124.9 days (SD = 185.6), with episodes consisting of 14.6 visits (SD = 28.6). The vast majority of women attended more than one visit (87.2%), typically returning within 2 weeks (mean 12.3 days, SD = 11.1). In addition to being pregnant or new mothers experiencing problematic substance use, most were unemployed, on social assistance, and single. CONCLUSIONS: Programs appeared to be able to successfully engage most women in treatment once they accessed the programs. Although rates of treatment participation did vary across subgroups defined by sociodemographic and admission characteristics, effect sizes tended to be small on average, providing little evidence in general of sociodemographic inequities in participation. Further work is needed to study the influence of program-level factors on participation, and how these link to maternal and child outcomes.

Risk for Childhood Internalizing and Externalizing Behavior Problems in the Context of Prenatal Alcohol Exposure: A Meta-Analysis and Comprehensive Examination of Moderators.

Prenatal alcohol exposure (PAE) is associated with a constellation of physical, neurocognitive, and behavioral abnormalities in offspring. The presence of internalizing (e.g., anxiety, mood disorders) and externalizing (e.g., oppositional defiant and conduct disorders) behavior problems has devastating and often long-lasting impacts on children, adolescents, and their families. The present meta-analysis explored the strength of the association between PAE and behavior problems, as well as factors that increase or mitigate risk. The current meta-analysis included 65 studies comparing children and adolescents with PAE to non- or light-exposed controls and attention-deficit/hyperactivity disorder (ADHD) samples, on a variety of internalizing and externalizing behavior outcomes. Results indicated that individuals with PAE are at increased risk for internalizing (d = 0.71, medium effect) and externalizing (d = 0.90, large effect) problems compared to control samples. The occurrence of total behavior problems was similar to that seen in ADHD samples. The strength of the association between internalizing and externalizing behavior problems and PAE was significantly moderated by several distinct sample characteristics, such as sample age, socioeconomic status, severity of exposure, and type of behavior problem. These findings further our understanding of the behavior problems experienced by children and adolescents with PAE.

We need psychologists!

Paediatricians are more likely than ever to encounter patients with mental health problems on a daily basis. There is a need for investment in proven treatments, such as psychology-based interventions, for children identified with mental health disorders. There are four main arguments supporting the engagement of psychologists for children with mental health problems: there is clear evidence that psychological interventions can effectively treat a wide range of mental health disorders; many parents and children are more open to exploring psychological therapies rather than medication for mental health problems; psychologists are trained and licensed to perform psychoeducational assessments, which can provide invaluable information about a child's learning profile, attention problems and overall intelligence; and behaviour problems in children can be prevented or improved through parent-based interventions. The authors' strongly advocate for the public funding of psychology services - both in collaborative primary care models and in the school setting.

Les pédiatres sont plus susceptibles que jamais de rencontrer quotidiennement des patients qui ont des troubles de santé mentale. L'investissement dans des traitements démontrés s'impose, tels que les interventions de nature psychologique, pour les enfants chez qui on décèle ce type de troubles. Quatre grands arguments appuient l'embauche de psychologues pour les enfants ayant des troubles de santé mentale : les données probantes démontrent clairement que les interventions psychologiques peuvent traiter des troubles de santé mentale très variés, de nombreux parents et enfants sont plus ouverts à explorer des thérapies psychologiques qu'à opter pour la médication dans ce contexte, les psychologues sont formés et détiennent un permis pour effectuer des évaluations psychoéducatives, ce qui peut fournir de l'information précieuse sur le profil d'apprentissage de l'enfant, ses troubles d'attention et son intelligence globale, et il est possible de prévenir ou d'atténuer des troubles de comportement chez les enfants grâce à des interventions des parents. Les auteurs préconisent fortement le financement public de services de psychologie, tant dans le cadre de modèles de soins coopératifs de première ligne qu'en milieu scolaire.

Executive Functioning in Children and Adolescents Prenatally Exposed to Alcohol: A Meta-Analytic Review.

Prenatal alcohol exposure is associated with a constellation of adverse physical, neurocognitive and behavior outcomes, which comprise a continuum of disorders labeled Fetal Alcohol Spectrum Disorders (FASD). Extant research has consistently identified executive functions (EF) as a central impairment associated with FASD. Despite this, heterogeneity exists regarding the strength of the association between FASD and different EF, and this association has not yet been quantitatively synthesized. The current meta-analysis reviews 46 studies that compare children and adolescents with FASD to participants without FASD, on a variety of EF measures. In accordance with Miyake et al. Cognitive Psychology, 41, 49-100 (2000) three-factor model of EF, findings for the primary EF domains of working memory, inhibition, and set shifting are reviewed. Results indicate that children and adolescents with FASD demonstrate significant deficits across these EF, although the magnitude of effects diverged between EF, with working memory and inhibition yielding medium effects and set shifting yielding large effects. These results were moderated by sample characteristics, type of FASD diagnosis, and EF methodology. This quantitative synthesis offers novel future research directions.

Maternal attachment and mind-mindedness: the role of emotional specificity.

We explored the relation between maternal mind-mindedness (i.e., a mother's tendency to verbally refer to her infant's mental world through use of infant-directed mental state terms) and maternal attachment. Mothers (N = 76), classified prenatally as Autonomous, Dismissing, Preoccupied, and Unresolved using the Adult Attachment Interview (AAI), simulated speaking to their 6-month-old infants in positive and negative emotion contexts. Mothers' utterances were coded for frequency of use of emotion and cognition-related mind-minded terms. Results indicated a significant negative relation between coherence of mind scores on the AAI and emotion mind-mindedness in the positive emotion context. When differences between insecure attachment categories and mind-mindedness were explored, results indicated that mothers with Preoccupied attachments were significantly more likely to use emotion-related terms than mothers with Dismissing attachments and that these differences were most pronounced in the negative emotion context. A similar pattern was found for mothers with Unresolved attachments compared to those with organized (Autonomous, Dismissing, Preoccupied) attachment classifications, however use of emotion mind-minded terms did not differ by emotional context. Future research directions highlighting the importance of exploring the unique contribution of Preoccupied, Dismissing and Unresolved attachment and emotional context in the exploration of mind-mindedness are discussed.

Reporting of feasibility factors in publications on integrated treatment programs for women with substance abuse issues and their children: a systematic review and analysis.

BACKGROUND: Implementation of evidence-based practices in real-world settings is a complex process impacted by many factors, including intervention, dissemination, service provider, and organizational characteristics. Efforts to improve knowledge translation have resulted in greater attention to these factors. Researcher attention to the applicability of findings to applied settings also has increased. Much less attention, however, has been paid to intervention feasibility, an issue important to applied settings. METHODS: In a systematic review of 121 documents regarding integrated treatment programs for women with substance abuse issues and their children, we examined the presence of feasibility-related information. Specifically, we analysed study descriptions for information regarding feasibility factors in six domains (intervention, practitioner, client, service delivery, organizational, and service system). RESULTS: On average, fewer than half of the 25 feasibility details assessed were included in the documents. Most documents included some information describing the participating clients, the services offered as part of the intervention, the location of services, and the expected length of stay or number of sessions. Only approximately half of the documents included specific information about the treatment model. Few documents indicated whether the intervention was manualized or whether the intervention was preceded by a standardized screening or assessment process. Very few provided information about the core intervention features versus the features open to local adaptation, or the staff experience or training required to deliver the intervention. CONCLUSIONS: As has been found in reviews of intervention studies in other fields, our findings revealed that most documents provide some client and intervention information, but few documents provided sufficient information to fully evaluate feasibility. We consider possible explanations for the paucity of feasibility information and provide suggestions for better reporting to promote diffusion of evidence-based practices.

Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes.

BACKGROUND: Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, dysfunctional parenting, and poor outcomes for mothers and children, yet there has been no systematic review of studies of parenting outcomes. OBJECTIVES: As part of larger systematic review to examine the effectiveness of integrated programs for mothers with substance abuse issues, we performed a systematic review of studies published from 1990 to 2011 with data on parenting outcomes. METHODS: Literature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline, the treatment program included at least one specific substance use treatment and at least one parenting or child service, and there were quantitative data on parenting outcomes. We summarized data on parenting skills and capacity outcomes. RESULTS: There were 24 cohort studies, 3 quasi-experimental studies, and 4 randomized trials. In the three randomized trials comparing integrated programs to addiction treatment-as-usual (N = 419), most improvements in parenting skills favored integrated programs and most effect sizes indicated that this advantage was small, ds = -0.02 to 0.94. Results for child protection services involvement did not differ by group. In the three studies that examined factors associated with treatment effects, parenting improvements were associated with attachment-based parenting interventions, children residing in the treatment facility, and improvements in maternal mental health. CONCLUSIONS: This is the first systematic review of studies evaluating the effectiveness of integrated programs on parenting. The limited available evidence supports integrated programs, as findings suggest that they are associated with improvements in parenting skills. However, more research is required comparing integrated programs to addiction treatment-as-usual. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the parenting needs of women with substance abuse issues.

Maternal sensitivity and overt aggression in young children with Down syndrome.

Children with genetic syndromes offer a unique opportunity to combine genetic and environmental approaches to the study of aggression. Children with genetic syndromes associated with developmental delay are at increased risk for behavior problems, but little is known about risk and resilience factors. In this study, we examined maternal sensitivity of mothers of children with Down syndrome using home observations when their children were 2, 3, and 5 years old, and relations with maternal reports and observations of overt aggression at school at age 5. Maternal sensitivity at ages 2 and 3 years did not significantly predict child aggression at age 5, but low maternal sensitivity at age 5 was significantly related to overt aggression at both home and school. By replicating and extending earlier work, this study informs developmental theory and identifies an important maternal variable related to aggression in children with Down syndrome.

Imagining the baby: Neural reactivity to infant distress and mind-mindedness in expectant parents.

Neural and psychological processes in pregnancy may be important antecedents for caregiving postpartum. Employing event-related potentials, we examined neural reactivity to infant emotional faces during the third trimester of pregnancy in expectant mothers (n = 38) and expectant fathers (n = 30). Specifically, expectant parents viewed infant distress and infant neutral faces while electroencephalography was simultaneously recorded. As a psychological measure, we assessed prenatal mind-mindedness towards the unborn child and examined whether neural processing of infant cues was associated with levels of mind-mindedness. Expectant fathers evidenced greater P300 reactivity to infant distress, relative to neutral, faces than expectant mothers. Furthermore, P300 reactivity to infant distress, relative to infant neutral, faces was associated with levels of prenatal mind-mindedness in expectant fathers but not expectant mothers. These findings indicate significant sex differences in the prenatal neural processing of infant cues and relations between neural reactivity to infant distress and the emergence of parental mind-mindedness.

Parenting Interventions for Mothers With Problematic Substance Use: A Systematic Review of Research and Community Practice.

Women with problematic substance use are frequently referred to interventions to promote positive parenting. Parenting interventions that attend to the unique risks faced by this population may enhance engagement and outcomes. While reviews of extant parenting interventions in the research literature have been undertaken, no studies have examined parenting interventions being implemented in community practice and the extent to which these are informed by current research. We systematically compared parenting interventions offered in 12 maternal substance use treatment programs in one Canadian province with those described in the research literature (K = 21). Few parenting interventions were replicated, either within or across the two samples. However, parenting interventions within both samples were largely similar in their objectives. Across both research and community samples, approximately half of the interventions were developed or adapted for a problematic substance use population. Parenting knowledge, psychosocial risk, and maternal emotional regulation were most commonly addressed. Risks pertaining to the impact of drug craving and substance-related changes in neurobiology associted with parenting were less commonly addressed. Findings highlight current strengths and limitations of parenting interventions within research and community settings, with recommendations offered for future research and knowledge translation.

Does Anxiety Enhance or Hinder Attentional and Impulse Control in Youth With ADHD? An ERP Analysis.

Objective: Youth with ADHD and comorbid anxiety (ADHD+ANX) experience increased social and academic impairment compared with youth with ADHD without anxiety (ADHD). Group differences in attentional and impulse control may underlie this increased impairment. Examination of group differences using behavioral measures of attentional and impulse control has yielded inconsistent findings. This study explored group differences using event-related potentials (ERPs), which provide neural information concerning early information processing. Method: ERPs (early frontal positivity [EFP], N2) were collected while youth aged 11 to 17 with ADHD (n = 31) and ADHD+ANX (n = 35) completed a visual and an auditory computer task. Results: Compared with the ADHD group, the ADHD+ANX group exhibited larger N2 amplitudes to no-go stimuli and larger EFP amplitudes to target auditory stimuli, with variable attention allocation to nontarget stimuli. Conclusion: The addition of anxiety to ADHD appears to alter early attentional processing, which may be an important aspect of this comorbidity.

Integrated programs for women with substance use issues and their children: a qualitative meta-synthesis of processes and outcomes.

BACKGROUND: There is a need for services that effectively and comprehensively address the complex needs of women with substance use issues and their children. A growing body of literature supports the relevance of integrated treatment programs that offer a wide range of services in centralized settings. Quantitative studies suggest that these programs are associated with positive outcomes. A qualitative meta-synthesis was conducted to provide insight into the processes that contribute to recovery in integrated programs and women's perceptions of benefits for themselves and their children. METHODS: A comprehensive search of published and unpublished literature to August 2009 was carried out for narrative reports of women's experiences and perceptions of integrated treatment programs. Eligibility for inclusion in the meta-synthesis was determined using defined criteria. Quality assessment was then conducted. Qualitative data and interpretations were extracted from studies of adequate quality, and were synthesized using a systematic and iterative process to create themes and overarching concepts. RESULTS: A total of 15 documents were included in the meta-synthesis. Women experienced a number of psychosocial processes during treatment that played a role in their recovery and contributed to favourable outcomes. These included: development of a sense of self; development of personal agency; giving and receiving of social support; engagement with program staff; self-disclosure of challenges, feelings, and past experiences; recognizing patterns of destructive behaviour; and goal setting. A final process, the motivating presence of children, sustained women in their recovery journeys. Perceived outcomes included benefits for maternal and child well-being, and enhanced parenting capacity. CONCLUSION: A number of distinct but interconnected processes emerged as being important to women's addiction recovery. Women experienced individual growth and transformative learning that led to a higher quality of life and improved interactions with their children. The findings support the need for programs to adopt practices that focus on improving maternal health and social functioning in an environment characterized by empowerment, safety, and connections. Women's relationships with their children require particular attention as positive parenting practices and family relationships can alter predispositions toward substance use later in life, thereby impacting favourably on the cycle of addiction and dysfunctional parenting.

Comparing Executive Functioning in Children and Adolescents With Fetal Alcohol Spectrum Disorders and ADHD: A Meta-Analysis.

Objective: Fetal alcohol spectrum disorders (FASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) are associated with a range of neurocognitive impairments. Executive functioning deficits are a hallmark feature of both disorders. Method: The present meta-analysis was undertaken to disentangle the behavioral phenotype of FASD and ADHD by quantitatively differentiating executive functioning differences between these two groups. The current meta-analysis reviews 15 studies comparing children and adolescents with FASD and ADHD to typically developing (TD) samples, on a variety of executive function measures. Results: Results indicate that when compared with TD samples, FASD and ADHD samples demonstrate significant executive function deficits (d = 0.82 and d = 0.55, respectively). In addition, FASD samples experience significantly greater deficits when compared with ADHD samples (d = 0.25). Results were moderated by IQ and socioeconomic status. Conclusion: These findings further our understanding of the cognitive differences between FASD and ADHD samples and have the potential to influence future basic research, assessment, and intervention.

An EEG Investigation of the Attention-Related Impact of Mindfulness Training in Youth With ADHD: Outcomes and Methodological Considerations.

OBJECTIVE: The current study examined the impact of an activity-based mindfulness treatment on EEG indices of attention in youth with ADHD aged 11 to 17 years compared with a waitlist control group. METHOD: Pre- and post-treatment, EEG was recorded as participants completed a single-point focus rest task and two active attention tasks. Theta power, beta power, and theta/beta ratio (TBR) were calculated during each task. RESULTS: A significant group by time by task interaction was found that indicated significant improvement in attentional ability, indexed by decreased TBR, for the treatment group but not controls. CONCLUSION: Findings support the benefit of mindfulness treatment for enhancing attentional control in youth with ADHD and extend the literature by providing evidence of these gains at a neural level. Findings also offer methodological support for the use of active attention tasks when examining mindfulness-related attentional gains in youth with ADHD. Directions for future research are discussed.

Community networks of services for pregnant and parenting women with problematic substance use.

Integrated treatment programs for pregnant and parenting women who use substances operate at the intersection of multiple service systems, including specialized substance use services, the broader health system, child protection, and social services. Our objectives were to describe the composition and structure of community care networks surrounding integrated treatment programs in selected communities in Ontario, Canada. We used a two-stage snowball method to collect network data from 5 purposively selected integrated treatment programs in communities in Ontario. Front-line staff with integrated treatment programs identified their top 5 service partners, who were then contacted and asked to provide the same information (n = 30). We used social network analysis to measure the cohesiveness, reciprocity, and betweenness centrality in the integrated treatment program's ego network. We described network composition in terms of representation of different service types. Across communities, common service partners were child protection, substance use or mental health services, parenting and child support, and other social services. Primary and pre-natal care, opioid agonist therapy, and legal services were rarely named as partners. Networks varied in network cohesiveness, as indicated by connectivity between the service partners and reciprocal ties to the integrated treatment programs. Integrated treatment programs commonly brokered the connections between other service partners. Findings suggest that these integrated treatment programs have achieved a level of success in developing cross-sectoral partnerships, with child protection services, parenting and child support, and social services featuring prominently in the networks. In contrast, there was a lack of close connections with physician-based services, highlighting a potential target for future quality improvement initiatives in this sector.

Integrated treatment programs for pregnant and parenting women with problematic substance use: Service descriptions and client perceptions of care.

Integrated treatment programs comprehensively address the unique and varied needs of pregnant and parenting women with problematic substance use. Despite the growth of these programs and evidence supporting their effectiveness, a clear picture of services that comprise integrated treatment is lacking. To address this gap in knowledge, we explored the services provided by 12 integrated treatment programs in one Canadian province. We found that integrated programs routinely provided substance use and mental health services, yet there was marked variability in other supportive services that address other central needs of women, such as prenatal and primary care, therapeutic childcare, housing and transportation support. Using survey data, we further examined client perceptions of care within integrated treatment programs (N = 106) compared to standard treatment programs (N = 207), and thematically analyzed qualitative feedback provided by integrated program clients to gain insight into how services may or may not be promoting positive perceptions of care. We found that integrated treatment program clients perceive their care more positively than clients in standard treatment programs and services provided impact on these perceptions. Implications for treatment development and research are discussed.