A comparative effectiveness study of the breaking the cycle and Maxxine Wright intervention programs for substance-involved mothers and their children: study protocol.

BACKGROUND: Children of substance-involved mothers are at especially high risk for exposure to adverse childhood experiences (ACEs) and poor mental health and development. Early interventions that support mothers, children, and the mother-child relationship have the greatest potential to reduce exposure to early adversity and the mental health problems associated with these exposures. Currently, there is a lack of evidence from the real-world setting demonstrating effectiveness and return on investment for intervention programs that focus on the mother-child relationship in children of substance-involved mothers. METHODS: One hundred substance-involved pregnant and/or parenting women with children between the ages of 0-6 years old will be recruited through the Breaking the Cycle and Maxxine Wright intervention programs, in Toronto, Ontario, Canada and Surrey, British Columbia, Canada, respectively. Children's socioemotional development and exposure to risk and protective factors, mothers' mental health and history of ACEs, and mother-child relationship quality will be assessed in both intervention programs. Assessments will occur at three time points: pre-intervention, 12-, and 24-months after engagement in the intervention program. DISCUSSION: There is a pressing need to identify interventions that promote the mental health of infants and young children exposed to early adversity. Bringing together an inter-disciplinary research team and community partners, this study aligns with national strategies to establish strong evidence for infant mental health interventions that reduce child exposure to ACEs and support the mother-child relationship. This study was registered with clinicaltrials.gov (NCT05768815) on March 14, 2023.

Cumulative Risk, Protection, and Early Intervention: Neurodevelopment in Sibling Groups Exposed Prenatally to Substances.

Mothercraft's Breaking the Cycle is an early intervention program for substance-exposed children with neurodevelopmental vulnerabilities. Within three substance-exposed sibling groups (N = 8; 0-6 years), we 1) described longitudinal neurodevelopmental trajectories, 2) explored the balance of cross-domain cumulative risk and protection on neurodevelopment, and 3) generated hypotheses on how cumulative risk, protection, and early intervention impact neurodevelopment. Neurodevelopment is potentially shaped by the balance of risk and protection. Postnatal risk (birth/postnatal, child, parent-child interaction) and relational protection (family, parent-child interaction) appear to have the most salient impact on neurodevelopment. Early intervention is thought to be important as soon as possible and before age 3 years.

A national implementation of a community-based intervention for mothers experiencing violence in relationships.

Interpersonal violence is a significant concern for families; thus interventions to support vulnerable mothers and children experiencing violence are essential. The purpose of this study was to present preliminary evaluation results from the national dissemination of an interpersonal violence intervention for mothers delivered in community-based programs across Canada. In 18 communities, 184 mothers participated in the intervention. Mothers reported on measures related to the self, relationships, parenting, and knowledge of community services, both before and after the intervention. Mothers comprised a high-risk, vulnerable population. Results indicated feasibility and acceptability, based on a high proportion of intervention completers and high levels of satisfaction. Women reported improvements in self-esteem, self-efficacy, relationship capacity, parenting stress, knowledge of community services, and understanding of relevant concepts compared to before the intervention (with small to medium effects). Additional analyses supported some of these findings as particularly robust. We discuss the importance of community-based projects in reaching diverse families, sustaining engagement with high levels of satisfaction, and supporting mothers in making changes relating to themselves, their relationships, and their parenting. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trauma-informed and relational approaches to service provision: building community-based project capacity to respond to interpersonal violence through a national initiative.

BACKGROUND: Community services that engage and service marginalized families can act as an important entry point for mothers and children experiencing interpersonal violence. The purpose of this study was to use an initiative that included training, implementation, and evaluation of an interpersonal violence intervention to understand changes in the capacity of service providers in community-based organizations to use trauma-informed and relational approaches to support mothers and children experiencing violence in relationships. METHODS: Participants (N = 27) were service providers from 14 community-based organizations across Canada, who had been trained to implement an interpersonal violence intervention with mothers in their communities. Using a phenomenological approach, participants engaged in an open-ended interview in which they were encouraged to reflect on their experiences in the intervention initiative, with prompts relating to the ways in which their work and their organization may have changed as a result of their participation. RESULTS: Findings indicated that participants were able to identify changes in four key areas related to trauma-informed practice: awareness (e.g., attitudes toward interpersonal violence), competency (e.g., application of trauma-informed knowledge), collaboration (e.g., working with other organizations to provide services to children and families), and safety (e.g., organizational policies to ensure safe, welcoming spaces). Further, participants identified these areas of change at the level of themselves as facilitators of the interpersonal violence intervention, their organizations, and their communities. CONCLUSIONS: Results indicate that, through training, implementation, and evaluation of an interpersonal violence intervention, service providers in community-based projects were able to extend trauma-informed and relational principles not only to the intervention itself, but also to their own work, as well as that of their organizations and communities. With some additional support, leveraging the existing capacities within community-based projects may be an effective means to support mothers and children experiencing interpersonal violence and other challenges.

Cumulative risk and protection measures data.

These data include clinically and theoretically grounded, cross-domain cumulative risk and protection measures. These measures were established for use with three sibling groups at Mothercraft's Breaking the Cycle (BTC), a child maltreatment prevention and early intervention program for substance using mothers and their children. These measures were established using archival data obtained from clients' charts. The cumulative risk factor measure encompasses: 1) items from a cumulative risk measure utilized in prior BTC research, 2) clinical measures assessing maternal mental health, addiction, and parenting capacity, 3) a measure utilized in studies on adverse childhood experiences, and 4) the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (Axis IV: Psychosocial Stressors) [1-3]. The cumulative protection factor measure encompasses: 1) existing early intervention components of services at BTC, 2) clinical measures assessing maternal mental health, addiction, and parenting capacity, and 3) known protective factors outlined in the literature. Both measures were theoretically grounded using the Developmental Model of Transgenerational Transmission of Psychopathology [4], which enabled salient domains of risk and protection to be delineated for children exposed prenatally to substances and accessing child maltreatment prevention and early intervention services. For a description of the process of establishing these measures, the total and cross-domain cumulative risk and protection percentages for the sample, as well as a qualitative interpretation of the balance between domains of risk and protection, see [5]. These measures can contribute to improved future understanding around cumulative risk and cumulative protection in vulnerable populations, salient domains of risk and protection, and the unique interaction that occurs between risk and protective processes in the context of child maltreatment prevention and early intervention.

Establishing clinically and theoretically grounded cross-domain cumulative risk and protection scores in sibling groups exposed prenatally to substances.

BACKGROUND: Prenatal substance exposure is associated with neurodevelopmental deficits. Deficits are exacerbated by cumulative risks yet attenuated by cumulative protective factors. Cross-domain relative to intra-domain risk exposure presents more neurodevelopmental challenges. Cumulative risk and protection scores must be clinically and theoretically grounded, with cross-domain considerations. OBJECTIVES: 1) Create clinically and theoretically grounded, cross-domain cumulative risk and protection scores; 2) Describe the benefits of our methodological approach. PARTICIPANTS & SETTING: This study included three sibling groups (N = 8) at Mothercraft's Breaking the Cycle, a child maltreatment prevention and early intervention program for substance using mothers and their children. METHOD: We outlined the process of establishing clinically and theoretically grounded, cross-domain cumulative risk and protection scores. Total and cross-domain cumulative risk and protection percentages, and the balance between domains of risk and protection, were explored. RESULTS: Clinically and theoretically grounded, cross-domain cumulative risk and protection scores were established. Total percentages were reported. Cross-domain profiles of cumulative risk and protection, and the number of significant domains of risk relative to protection, were reported. The cross-domain profiles facilitated consideration of intra- and inter-domain risk and protection within and between sibling groups. CONCLUSIONS: Emerging patterns indicate the importance of establishing cumulative risk and protection scores that are: 1) clinically and theoretically grounded, 2) cross-domain, and 3) encompass cumulative protection and risk. In understanding profiles of risk and protection, we can inform evidence-based early interventions that address: 1) high-risk children, 2) the full range of risks, 3) vulnerable domains, and 4) protective factors.

Developing and testing a readiness tool for interpersonal violence prevention partnerships with community-based projects.

Community-based projects that serve vulnerable families have the opportunity to identify and respond to interpersonal violence (IPV). We developed a readiness assessment tool to support selection of projects to participate in an initiative that involved implementing a community-based IPV intervention for mothers. The overarching aim of the current study was to describe the development of this tool and examine the reliability of coding, validity, and utility of the tool. After developing and refining the tool, 41 community-based projects completed the tool. Responses were coded and scored; scores were used to select projects for the initiative. Preliminary validation for the tool included (a) expert opinion, (b) uptake/implementation of the intervention, and (c) feedback and responses from service providers in terms of the usefulness and importance of the tool. This tool can be used by both researchers and service providers to assess community project readiness and capacity to provide trauma-informed services for vulnerable families.

Using a Developmental-Relational Approach to Understand the Impact of Interpersonal Violence in Women Who Struggle with Substance Use.

Substance use among women is a major public health concern. This review article takes a developmental-relational approach to examine processes through which early relational trauma and violence in relationships may lead to substance use. We examine how early exposure to violence in relationships can impact neurological development, specifically through interference with physiological mechanisms (e.g., the hypothalamic-pituitary-adrenal axis), brain structure and functioning (e.g., the hippocampus and prefrontal cortex), and neuropsychological development (e.g., executive functioning and emotion regulation) across the lifespan. Further, we discuss the impact of exposure to violence on the development of relational capacity, including attachment, internal working models, and subsequent interpersonal relationships across the lifespan, and how these developmental pathways can lead to continued problematic substance use in women.

Addressing the Impact of Interpersonal Violence in Women Who Struggle with Substance Use Through Developmental-Relational Strategies in a Community Program.

From a developmental-relational framework, substance use in women can be understood as relating to early experiences of violence in relationships and across development. This article uses a developmental-relational approach to outline specific strategies that can be used by service providers and to guide interventions for women with substance use issues. By reviewing research and clinical work with women attending a community-based prevention and early intervention program, we describe how specific components of programming can target the developmental and intergenerational pathway between experiences of violence in relationships and substance use. We include the voices of women who attended the program to support the strategies discussed. Specifically, these strategies address the impact of interpersonal violence on substance use by promoting the process of repair and reintegration for women whose neurological development, sense of self, and capacity to form relationships have been significantly impacted by experiences of violence in relationships.

Reasons for substance use continuation and discontinuation during pregnancy: A qualitative study.

BACKGROUND: Substance use during pregnancy is a major public health concern, stemming from potential physical and psychosocial harms to both the mother and child. PURPOSE: To understand women's experiences using substances during pregnancy and the reasons that women continue and/or discontinue using substances. METHODS: Focus groups were conducted with women who attended an early intervention program for pregnant or parenting women with substance use issues. RESULTS: Women identified that external and internal stressors, feelings of guilt and low-self efficacy, and a lack of understanding of the scientific and medical consequences of substance use contributed to their continued substance use. Conversely, women highlighted the importance of high self-efficacy and the quality of relationships when trying to make positive changes to their substance use during pregnancy. CONCLUSIONS: Recommendations are proposed for easier access to and more comprehensive services. Healthcare professionals and service providers should offer non-judgmental care by building high-quality relationships with pregnant women with substance use issues, to increase these women's self-efficacy and empower them to discontinue substance use.

Engaging mothers with substance use issues and their children in early intervention: Understanding use of service and outcomes.

Mothers who use substances need integrated, multi-sectoral intervention services to support substance use discontinuation. We explored mothers' service use at Breaking the Cycle, an early intervention and prevention program for pregnant and parenting women and their young children in Toronto, Canada. We conducted retrospective analyses of families' service records and client charts (N = 160). Aims were to 1) describe women's use of service, 2) examine how early engagement of pregnant women related to postnatal service use, and 3) examine the circumstances in which women ended their service relationship with Breaking the Cycle. Specifically, we examined circumstances at service ending relating to women's service goals; custody status with children; and global substance-use, parent-child relationship, and child development outcomes. We found that these vulnerable women were actively engaged in many services and for a long duration, early engagement was associated with greater service use, and greater service use was associated with more positive circumstances upon ending service. Results provide support for a relational approach to service that promotes not only the relationship between mother and child, and mother and service provider, but also highlights relationships among staff, between staff and management, and between community partners as integral to effective service delivery. Integrating positive relationships at all levels is critical to support vulnerable families with complex needs.

Estimating the neurocognitive effects of an early intervention program for children with prenatal alcohol exposure.

BACKGROUND: Animal studies suggest that early intervention in pups exposed heavily to ethanol in utero can mitigate their neurocognitive damage. No human studies on this promising mechanism exists. METHODS: Breaking the Cycle is an early intervention program for drug-and alcohol addicted mothers and their young children. We compared BSID-III scores between infants heavily exposed to ethanol and a group exposed only to drugs of abuse, mainly cocaine. Both groups benefited from all aspects of our early intervention program. RESULTS: The two groups did not differ in any aspect of the BSID-III. These data are in contradistinction to the damage seen in heavily ethanol- exposed infants not benefiting from early intervention. CONCLUSIONS: This pilot suggests that early intervention may mitigate some of the well described damages caused by heavy in utero alcohol exposure.

Perspectives of mothers with substance use problems on father involvement.

BACKGROUND: A number of complex factors contribute to pregnant and parenting women's alcohol and substance use. To date, little research has focused on the implications, meaning and experiences of father involvement on mothers with substance use problems. OBJECTIVE: The current study explores the experiences of mothers with substance use problems with respect to the role, impact and meaning of father involvement. METHODS: This study conducted two focus groups utilizing a phenomenological approach. Mothers receiving clinical services at a comprehensive, community based program serving pregnant and parenting women with substance use problems were recruited to participate in this research. RESULTS: The meaning of father involvement among this group of women centered on four dimensions: emotional support, financial contributions to the family, amount and quality of time spent with the children and the family, and was dependent upon the particular expectations of the mother involved. Barriers and influences of father involvement were identified. The nature of father involvement had negative and positive impacts on participants. DISCUSSION: Maternal use of alcohol is a complex issue, one factor often ignored in father involvement. For mothers with substance use problems father involvement has a number of implications, both positive and negative.