Evaluating outcomes of a three-year case management program for mothers with prenatal substance use according to race/ethnicity, Washington State, 2006-2017.

BACKGROUND: Well-designed public health interventions ideally aspire to reduce health disparities between racial and ethnic groups. Yet, there remains virtually no research examining racial/ethnic disparities in interventions for marginalized perinatal populations with substance use disorders (SUD). We sought to examine whether there were racial/ethnic differences at intake, in retention, and in program outcomes among pregnant or postpartum women with prenatal substance use enrolled in a three-year intensive case management intervention. We hypothesized that: (1) at baseline, numerous racial/ethnic disparities in well-being, health, and health care would be observed, and (2) after the three-year intervention few racial/ethnic disparities in maternal and child health and welfare would be found. METHODS: We used self-reported data from 3,165 women aged 18 to 45 years enrolled in the Parent-Child Assistance Program in Washington State between May 10, 2006, and September 21, 2017. We used Fisher-Freeman-Halton Exact Tests and t-tests to compare racial/ethnic groups at program enrollment and exit and logistic regression to examine likelihood of completing the intervention by group, controlling for other factors. RESULTS: Despite numerous racial/ethnic differences at enrollment, there were no such differences in outcomes among those who finished the program and completed an exit interview. Different racial/ethnic groups received comparable case manager time. American Indians/Alaska Natives were less likely to finish the program (Adjusted Odds = 0.66). CONCLUSIONS: Participants who finished the program achieved comparable outcomes regardless of race/ethnicity. More work is needed to understand why American Indian/Alaska Native women were less likely than the others to finish the program and to close this service gap.

Prenatal alcohol exposure and mental health at midlife: A preliminary report on two longitudinal cohorts.

BACKGROUND: Although the effects of prenatal alcohol exposure (PAE) have been studied extensively, there is relatively little information available on adult mental health functioning among exposed individuals. The current study compares the self-reported midlife mental health status of individuals who were prenatally exposed to alcohol and diagnosed in childhood with the effects of this exposure with that of unexposed individuals. METHODS: Participants (N = 292) were recruited from two longitudinal cohorts in Atlanta and Seattle and asked to complete an Adult Health Questionnaire that surveyed their current health and mental health status. The questionnaire was completed either in-person or remotely and included questions about current symptoms of depression and anxiety and mental health disorder diagnoses. The analysis compared a Nonexposed Contrast group to those in two exposure groups: (1) Alcohol Exposed with Fetal Alcohol Effect but not meeting criteria for Fetal Alcohol Syndrome (FAS) and (2) Alcohol Affected and meeting criteria for FAS. RESULTS: Both alcohol-exposed groups reported higher levels of current depressive symptoms and a higher prevalence of diagnoses of depression, anxiety, bipolar disorder, and/or attention deficit/hyperactivity disorder. No differences were noted for psychotic disorders. PAE was also associated with greater environmental stressors, including higher levels of adverse childhood events and lower current socioeconomic status. Path analyses suggested that PAE was indirectly related to mood disorders with its effects being mediated by other environmental factors. CONCLUSIONS: PAE is associated with greater rates of mental health disorders in middle adulthood. These outcomes appear to result from multiple stressors that affect individuals made vulnerable by their early alcohol exposure. Clinical outcomes could be improved by prevention efforts directed at preventing prenatal alcohol use and reducing environmental stressors later in life, and by the early identification of PAE and its effects.

Predictors and moderators of improved social-emotional functioning in mothers with substance use disorders and their young children enrolled in a relationship-based case management program.

Mothers with substance use disorders (SUDs) typically have trauma histories and psychosocial difficulties that lead to poor social-emotional functioning and disrupted mother-child relationships. This 12-month study explored associations of family adverse circumstances and services (case management, therapeutic, and community-based) received by 57-mothers with SUDs and their infants (less than 24-months-old) with changes in social-emotional functioning. All mothers were enrolled in a relationship-based case management program (Parent-Child Assistance Program [PCAP]) that emphasized connecting mothers to appropriate community services. A subset of mothers was additionally provided a trauma-focused psychotherapeutic intervention (infant-parent psychotherapy [IPP]). Dyads in both treatment groups improved in overall social-emotional functioning as assessed by the Functional Emotional Assessment Scale (FEAS). A combined-sample regression analysis revealed that improved FEAS scores were significantly predicted by the number of community services received but not by PCAP case management hours (IPP was not included in this analysis). More adverse circumstances were associated with less improvement in social-emotional functioning in the children; but among the mothers trauma level did not predict FEAS scores. We also found a moderating effect of trauma: Dyads with relatively more adversity showed a significantly greater association of community services received with improvement in FEAS scores than did those with relatively less adversity.

Las madres con trastornos por abuso de sustancias (SUDs) típicamente tienen historias de trauma y dificultades sicosociales que conducen al débil funcionamiento socio-emocional y relaciones madre-niño trastornadas. Este estudio de 12 meses exploró asociaciones entre circunstancias adversas de familia y servicios (de dirección de caso, terapéuticos, basados en la comunidad) que recibieron 57 madres con SUDs y sus infantes (menos de 24 meses de edad) con cambios en el funcionamiento socio-emocional. Todas las madres fueron inscritas en un programa de dirección de caso con base en la relación (Programa de Asistencia al Progenitor y Niño - PCAP) que enfatizaba la conexión de las madres con adecuados servicios comunitarios. Un subgrupo de madres recibió además una intervención sicoterapéutica con enfoque en el trauma (Sicoterapia de Infante-Progenitor - IPP). Las díadas en ambos grupos de tratamiento mejoraron en el funcionamiento socio-emocional en términos generales tal como se les evaluó por medio de la Escala Funcional de Evaluación Emocional (FEAS). Un análisis de regresión que combinó los grupos muestras reveló que los mejorados puntajes en FEAS habían sido pronosticados significativamente por el número de servicios comunitarios recibidos, pero no por las horas del programa de dirección de caso PCAP (no se incluyó la IPP en este análisis). Se asociaron las circunstancias más adversas con un menor mejoramiento en el funcionamiento socio-emocional en los niños; pero entre las madres, el nivel del trauma no predijo los puntajes FEAS. También encontramos un efecto moderador del trauma: las díadas con más adversidad relativamente mostraron significativamente mayor asociación de servicios comunitarios recibidos con mejoras en los puntajes FEAS que aquellas con menor adversidad relativamente. Palabras claves: Salud mental infantil, trastornos maternos por abuso de sustancias, trauma, servicios comunitarios, Sicoterapia de Infante-Progenitor.

Les mères ayant des troubles liés à la toxicomanie (TLT) ont typiquement des passés de trauma et des difficultés psychosociales qui mènent à un mauvais fonctionnement socio-émotionnel et à des relations mère-enfant perturbées. Cette étude de 12 mois a exploré les liens de circonstances familiales adverses et les services (gestion des cas, services thérapeutiques, et services au niveau de la communauté) reçus par 57 mères ayant des TLT et leurs bébés (moins de 24 mois) avec des changements dans le fonctionnement socio-émotionnel. Toutes les mères ont été inscrites dans un programme de gestion de cas basé sur la relation (Programme d'Assistance Parent-Enfant) mettant l'accent sur la référence des mères aux services communautaires appropriés. Un sous-groupe de mères a en plus reçu une intervention psychothérapeutique centrée sur le trauma (Psychothérapie Bébé-Parent). Les dyades des deux groupes de traitement se sont améliorées dans le fonctionnement socio-émotionnel général, évalué par l'Echelle d'Evaluation Emotionnelle Fonctionnelle (Functional Emotional Assessment Scale, soir FEAS). Une analyse de régression d'échantillons combinés a révélé que les scores FEAS améliorés étaient fortement prédits par le nombre de services communautaires reçus mais pas par les heures de gestion de cas FCAP (l'IPP n'a pas été inclue dans cette analyse). Plus de circonstances adverses était lié à moins d'amélioration dans le fonctionnement socio-émotionnel chez les enfants. Mais chez les mères le niveau de trauma ne prédisait pas les scores FEAS. Nous avons aussi découvert un effet modérateur du trauma: les dyades avec relativement plus d'adversité faisaient preuve d'une association bien plus élevée avec les services communautaires reçus avec une amélioration dans les scores FEAS que les dyades avec relativement moins d'adversité. Mots clés: Santé Mentale du Nourrisson, Troubles Liés à la Toxicomanie Maternelle, Trauma, Service Communautaires, Psychothérapie Bébé-Parent.

Intervention with substance-abusing mothers: are there rural-urban differences?

OBJECTIVE: The purpose of this study was to examine rural-urban differences among substance-abusing mothers enrolled in the Parent-Child Assistance Program (PCAP) from 1998 to 2008 in Washington State. METHODS: This was a longitudinal study utilizing PCAP data reports of 773 women enrolled from 1998 to 2008. Differences across urban-rural PCAP participants were examined. RESULTS: Rural participants were more likely to report alcohol use and binge drinking at program intake and at the 3-year program exit. In addition, throughout the program, rural women were less likely to complete outpatient substance abuse treatment compared to urban participants. Rural women also used less services during the last year including alcohol/drug support and mental health provider services. Findings are troubling when we consider that at program exit, rural participants also reported higher use of alcohol and more suicidal thoughts than those residing in urban areas. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Data presented indicate there are important differences between urban and rural residing participants. Findings highlight the importance of considering the barriers that rural or remote locations might create. Identifying community-specific needs of substance abusing pregnant or parenting women in both rural and urban settings is crucial for the successful development and improvement of treatment and intervention programs for this vulnerable population of women.

Intervention with substance-abusing mothers: Are there rural-urban differences?

OBJECTIVE: The purpose of this study was to examine rural-urban differences among substance-abusing mothers enrolled in the Parent-Child Assistance Program (PCAP) from 1998 to 2008 in Washington State. METHODS: This was a longitudinal study utilizing PCAP data reports of 773 women enrolled from 1998 to 2008. Differences across urban-rural PCAP participants were examined. RESULTS: Rural participants were more likely to report alcohol use and binge drinking at program intake and at the 3-year program exit. In addition, throughout the program, rural women were less likely to complete outpatient substance abuse treatment compared to urban participants. Rural women also used less services during the last year including alcohol/drug support and mental health provider services. Findings are troubling when we consider that at program exit, rural participants also reported higher use of alcohol and more suicidal thoughts than those residing in urban areas. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Data presented indicate there are important differences between urban and rural residing participants. Findings highlight the importance of considering the barriers that rural or remote locations might create. Identifying community-specific needs of substance abusing pregnant or parenting women in both rural and urban settings is crucial for the successful development and improvement of treatment and intervention programs for this vulnerable population of women. (Am J Addict 2014;XX:1-9).

The effectiveness of a community-based intervention program for women at-risk for giving birth to a child with Fetal Alcohol Spectrum Disorder (FASD).

The goal of this study was to determine whether the First Steps program (modeled after the Parent-Child Assistance Program) resulted in improved outcomes among women at-risk for giving birth to a child with FASD. We conducted a retrospective analysis of data on 70 participants in the First Steps program. Clients were high risk and faced many life challenges, including: being on welfare, substance abuse, physical and sexual abuse as children, mental health issues, criminal activity, and unplanned pregnancies. We found a significant increase in birth control use and decrease in welfare rates from pre- to post-program. At program exit, many participants were abstinent from alcohol and/or drugs and the majority did not experience a subsequent pregnancy. Clients also showed significant increases in goals and decreases in needs from pre-to post-program. The First Steps program demonstrated promising outcomes for women at-risk for giving birth to a child with FASD.

Carrying the burdens of poverty, parenting, and addiction: depression symptoms and self-silencing among ethnically diverse women.

Depression among women commonly co-occurs with substance abuse. We explore the association between women's depressive symptoms and self-silencing accounting for the effects of known childhood and adult risk indicators. Participants are 233 ethnically diverse, low-income women who abused alcohol/drugs prenatally. Depressive symptomatology was assessed using the Addiction Severity Index. Multivariate logistic regression models examined the association between self-silencing and the dependent depression variable. The full model indicated a 3% increased risk for depressive distress for each point increase in self-silencing score (OR = 1.03; P = .001). Differences in depressive symptomatology by ethnic groups were accounted for by their differences in self-silencing.

Alcohol use before and during pregnancy in western Washington, 1989-2004: implications for the prevention of fetal alcohol spectrum disorders.

OBJECTIVE: We examined trends in rates of self-reported pregnancy alcohol use among women in western Washington. STUDY DESIGN: Between 1989 and 2004, we conducted 3 studies in western Washington State on problems that are associated with maternal prenatal alcohol or drug abuse (n = 12,526). To determine study eligibility, we screened hospitalized postpartum women for alcohol and drug use in the month before and during pregnancy. We examined trends in alcohol use rates and identified characteristics that were associated with any drinking and binge drinking (> or = 5 drinks on any occasion). RESULTS: We found a substantial decrease in pregnancy alcohol use between 1989 and 2004 (from 30-12%) across almost all demographic categories. Binge drinking in the month before pregnancy increased significantly among all race categories, except Native American. CONCLUSION: Increased prepregnancy binge drinking rates may estimate alcohol use during very early gestation and warrant clinical attention because of the potential for fetal alcohol spectrum disorders.

Use of Marijuana and Other Substances Among Pregnant and Parenting Women With Substance Use Disorders: Changes in Washington State After Marijuana Legalization.

OBJECTIVE: In 2012, possession of marijuana for nonmedical use was legalized in Washington State. This study examined how legalization affected alcohol and drug use in a sample of pregnant and parenting women with substance use disorders. METHOD: Study participants from nine counties in Washington State (N = 1,359) were questioned about their substance use after completing a 3-year case management intervention program. The sample was divided into two cohorts based on whether participants had completed the program before or after legalization. RESULTS: Most study participants reported complete abstinence from alcohol and nonprescription drugs at program exit. Among those who were still using substances, women who completed the intervention after marijuana legalization were significantly more likely to report marijuana use at program exit compared with women who completed the intervention before marijuana legalization. Across both cohorts (pre- and post-legalization), we found a positive association of exit marijuana use with alcohol, illegal methadone, other opioids, amphetamines, and cocaine use; even when we controlled for historical period, the association with some of these substances with marijuana use remained evident. Independent of marijuana use, we saw increased use during the post-legalization period of alcohol, illicit methadone, and other opioids. CONCLUSIONS: Marijuana use at exit from the Parent-Child Assistance Program (PCAP) increased significantly after marijuana legalization in the state. Women who were not abstinent from marijuana at program exit were likely to report use of other substances as well. Our study design demonstrates an association but does not allow us to conclude that marijuana use leads to other substance use among this sample of women with a history of polysubstance use.

Hospitalization and infant outcomes among women exposed and unexposed to tocolysis.

OBJECTIVE: To examine whether infants exposed to tocolytics are at increased risk for selected adverse clinical and hospitalization outcomes. STUDY DESIGN: We conducted a population-based cohort study of women with preterm labor, in Washington State from 1989 to 2001 (N=79,679), using linked hospitalization records. Relative risks for infant outcomes were estimated using multivariate logistic regression. RESULTS: Adjusted risk estimates for infants exposed to tocolysis were greater for respiratory distress (RR=1.5, 95% CI 1.4 to 1.6), intubation (RR=1.4, 95% CI 1.2 to 1.5), and bacterial infection (RR=1.6, 95% CI 1.4 to 1.8). Exposed infants were also more likely to have birth hospitalizations >2 days (RR=1.4, 95% CI 1.3 to 1.4), require transfer (RR=1.5, 95% CI 1.3 to 1.8), have increased hospital costs (RR=2.3, 95% CI 2.2 to 2.4), and require readmisssion within the first year of life (RR=1.2, 95% CI 1.1 to 1.3). CONCLUSION: Infants exposed to tocolytics appeared to have relatively poorer hospitalization and clinical outcomes; significant benefits were not observed.

Prenatal alcohol exposure: An assessment strategy for the legal context.

Studies over the last two decades have shown that people with fetal alcohol spectrum disorders (FASD) have the kind of brain damage that increases risk of criminal behavior. Thus, it is generally accepted that FASD is likely to affect a sizable minority of individuals involved in the justice system. Most of these defendants have never been diagnosed because they lack the facial abnormalities and severe intellectual deficiency that would have improved identification and diagnosis in childhood. Despite the fact that an FASD diagnosis and associated cognitive deficits may be directly relevant to offense conduct and post-arrest capacities, screening for prenatal alcohol exposure (PAE) by legal teams remains relatively rare. This article addresses the relatively straightforward screening process with strategies that may be used singly or in combination to produce information that can establish PAE and provide a foundation for diagnostic assessment by medical and mental health experts.

The impact of prenatal alcohol exposure on addiction treatment.

Fetal alcohol spectrum disorders (FASDs) are conditions caused by prenatal alcohol exposure in amounts sufficient to cause permanent deficits in brain functioning. Extent of damage largely depends on timing, dose, frequency, and pattern of exposure. Timing is especially important because prenatal alcohol exposure during critical periods of gestation can affect brain development in ways that produce varying patterns of neurocognitive deficits and associated adaptive impairments. This article describes some of the more serious neurophysiological and neuropsychological sequelae of prenatal alcohol exposure that contribute to increased risk for substance abuse problems among people with an FASD. We discuss the unique interface between pharmacological treatment and FASD, noting that failure to consider the possibility of FASD in treatment planning may result in treatment failure and/or relapse. Finally, we present a clinical case example and recommend service accommodations to address some of the impairments in FASD that limit substance abuse treatment success.

Does rural residence affect access to prenatal care in Oregon?

CONTEXT: Identifying how maternal residential location affects late initiation of prenatal care is important for policy planning and allocation of resources for intervention. PURPOSE: To determine how rural residence and other social and demographic characteristics affect late initiation of prenatal care, and how residence status is associated with self-reported barriers to accessing early prenatal care. METHODS: This observational study used data from the 2003 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) (N = 1,508), with late initiation of prenatal care (after the first trimester) as the primary outcome. We used Rural-Urban Commuting Area (RUCA) codes to categorize maternal residence as urban, large rural, or small/isolated rural. Multivariate logistic regression was used to evaluate whether category of residence was associated with late initiation of prenatal care after adjusting for other maternal factors. Association between categories of barriers to prenatal care and maternal category of residence were determined using the Cochran-Mantel-Haenszel test of association. FINDINGS: We found no significant association between residence category and late initiation of prenatal care, or residence category and barriers to prenatal care initiation. Urban women tended to be over age 34 or nonwhite. Women from large rural areas were more likely to be younger than 18 years, unmarried, and have an unintended pregnancy. Women from small rural areas were more likely to use tobacco during pregnancy. CONCLUSIONS: Maternal residence category is not associated with late initiation of prenatal care or with barriers to initiation of prenatal care. Differences in maternal risk profiles by location suggest possible new foci for programs, such as tobacco education in small rural areas.

Preventing alcohol and drug exposed births in Washington state: intervention findings from three parent-child assistance program sites.

Home visitation interventions show promise for helping at-risk mothers, yet few programs have been developed and evaluated specifically for alcohol and drug-abusing pregnant women. This study examines outcomes among 216 women enrolled in the Washington State Parent-Child Assistance Program, a three-year intervention program for women who abuse alcohol and drugs during an index pregnancy. Pretest-posttest comparison was made across three sites: the original demonstration (1991-1995), and the Seattle and Tacoma replications (1996-2003). In the original demonstration, the client group performed significantly better than controls. Compared to the original demonstration, outcomes at replication sites were maintained (for regular use of contraception and use of reliable method; and number of subsequent deliveries), or improved (for alcohol/drug treatment completed; alcohol/ drug abstinence; subsequent delivery unexposed to alcohol/drugs). Improved outcomes at replication sites are not attributable to enrolling lower-risk women. Public policies and programs initiated over the study period may have had a positive effect on outcomes. Study findings suggest that this community-based intervention model is effective over time and across venues.

Three-year developmental outcomes in children with prenatal alcohol and drug exposure.

PURPOSE: The purpose of this study was to describe the performance of children whose mothers abused alcohol and drugs heavily during pregnancy, using the Bayley Scales of Infant Development Second Edition (BSID-II) at three years, and to examine the effects of study group, prenatal binge alcohol exposure, and prematurity on developmental outcome. METHODS: Children were born to mothers recruited from two large hospitals or through community referral. Hospital recruits were randomly assigned to either a three-year paraprofessional home visitation intervention program (n = 30) or a control group (n = 31). Community recruits were enrolled in the intervention program (n = 35). RESULTS: Among all children the mean BSID-II Mental Developmental Index (MDI) was 84.4 (SD = 14.4) and mean Psychomotor Developmental Index (PDI) was 84.1 (SD = 16.9). Box plots of the MDI and PDI scores by study group, maternal prenatal binge alcohol status, and a binary indicator of prematurity suggested an effect of maternal binge drinking on MDI and PDI scores: children of mothers with a history of binge alcohol consumption have, on average, slightly lower scores. We saw no evidence of a systematic effect of the maternal intervention. CONCLUSIONS: Developmental performance of preschool children exposed to alcohol and drugs prenatally was, on average, substantially lower than expected for age regardless of study group. Although this home visitation intervention has been shown to be effective in helping mothers address a wide spectrum of needs, it is unlikely sufficient to overcome complex developmental risks of children exposed to alcohol and drugs prenatally. The effect of more comprehensive, multidimensional services specifically designed for the children should be investigated within this context.

A pilot community intervention for young women with fetal alcohol spectrum disorders.

Fetal Alcohol Syndrome, a permanent birth defect caused by maternal alcohol use during pregnancy, is a leading preventable cause of mental retardation. Neuropsychological deficits have been well documented, however interventions developed have not been evaluated. We describe a successful 12-month community pilot intervention with 19 young women with Fetal Alcohol Spectrum Disorders (FASD). Improved outcomes (including decreased alcohol and drug use, increased use of contraceptives and medical and mental health care services, and stable housing) were obtained by implementing a community intervention model of targeted education and collaboration with key service providers, and by using paraprofessional advocate case managers as facilitators.