Quality of Care Giving in Substance Abuse Mothers

Quality of caregiving in substance abusing Quality of caregiving in substance abusing mothers: The potential impact and mothers: The potential impact and treatment implications of co morbid treatment implications of co morbid

impulse control disorders impulse control disorders

Sharon Dawe, Denise Hatzis, Paul Harnett & Jane Barlow

[email protected]

What we knowSubstance abuse is associated with:

Increased risk for child maltreatment and neglect

Poorer child outcomes, early school failure, use of substances poor social skills, affect dysregulation.

Greater involvement of child protection agencies and children being removed from parental custody

High rates of comorbid MATERNAL psychopathology

Caregiving in substance abusing mothers

BUT WHAT DOES THIS MEAN ON A BUT WHAT DOES THIS MEAN ON A

CASE BY CASE BASIS?CASE BY CASE BASIS?

Caregiving in substance Caregiving in substance abusing mothersabusing mothers

Intergenerational transmission of insecure attachment

Childhood and adult trauma of mother

Presence of co morbidpsychopathology

Reduced perception of available social supportespecially spousal support

Compromised caregiving is influenced by multiple factors

Five Attachment Studies Identified:Swanson et al. (2000) Part of Longitudinal study :51 S/A dyads Explore intrusive caregiving and quality of attachment at 1, 6 & 18 mths KEY FINDING:@ 18 mths - toddlers – 19% Secure, 14% Avoidant, 4% Resistant & 45% disorganised

Espinosa et al. (2001) : 35 cocaine–using mothers 18 mths toddlers – 31% secure, 14% avoidant, 6% resistant, & 49% of toddlers disorganised ↓ sensitive caregiving at 1 & 6 mths assoc. sig with toddlers with disorganised attachment

Reviewing the data on attachment classification in substance abusing mothers

Beeghly et al. (2003): 29 heavy cocaine exposed, 61 light cocaine exposed, 64 no cocaine exposure.KEY FINDING:12 mths toddlers overall – 59% secure, 10% avoidant, 6% resistance, & 21% disorganised.

Seifer et al. (2004) Prospective study 860 dyads at 18 mths 732 at 36 mthsKEY FINDING: 18 & 36 mthsSecure > 65-69%;Disorganise < 12% - 6 %, Ambivalent > 8 %- 14%;Avoidant< 11% -9%. Cocaine + opiate mothers ↓ secure children

Reviewing the data on attachment classification in substance abusing mothers

What does this tell us?

Highlights the variability in studies

Raises questions about the quality of caregiving – suggesting that in many cases it is certainly “good enough”

But can we glean anything from the literature on what may determine when the caregiving will be “good enough”?

Systematic review: reviews all published and “gray” literature by developing a set of search terms,

Meta analysis: studies meeting these search terms are then further analyses. Data is extracted from each study and combined into a single analysis.

Undertaking a systematic review & meta analysis

SEARCH TERMS:Key words were entered for the following title and abstract search: (maternal substance use OR maternal drug use OR substance using mothers OR drug using mothers) AND (caregiving OR care giving OR interaction). All data bases including OVID, PSYCH INFO Medline.

(PRISMA Guidelines followed)


INCLUSION CRITERIA:

(i)quantitative study; (ii)antenatal maternal substance use; (iii)infants were less than three years of age when maternal-infant interactions were assessed; (iv) maternal-infant interactions were assessed using an observational method, videotaped and coded to assess the quality of caregiving (v)studies needed to include a comparison group of non-substance using mothers.


EXTRACTED DATA ON Maternal sensitivity: maternal response to infant or child cues related to maternal warmth in situations of low frustration rather than during situations of frustration or negative affect

Child responsivity: explicitly measure involvement or responsiveness of the infant such as “involvement with the mother, positive feelings shown to mother

Independently coded (SD & JB)


Standardised effect sizes (d) were calculated for the included studies using a random-effects model A forest plot was calculated in Review Manager 5 (Version: 5.3.5) and the heterogeneity between studies was assessed using the Q statistic and I2 index. Sub-group analyses were carried out to investigate sources of heterogeneity. Sensitivity analyses using a priori weight functions were carried out to determine whether the estimates of effect size were likely to be influenced by publication bias.


Substance use matters – but note the effect sizes are small and only just significant

In treatment/out of treatment no difference

Methadone/or other substitution therapy no difference

Poverty matters – financial disadvantage, receipt of MediAid, low SES, - a lot

What appear to be the factors implicated in caregiving quality?

Co morbid psychopathology could not be tested in the meta analysis

However, narrative analysis of the few studies that have investigated this suggest this matters – a lot.

Maternal psychopathology (9 studies)Depression – 4 studiesParanoia, narcissism, features of borderline – 3 studiesPersonality features and Maternal aggression – 2 studies


In all of these studies co morbid psychopathology was significantly associated with the quality of care.However, it is difficult to tease apart the relative contribution of this and substance abuse.

My interpretation of this data: 1.Substance use does not preclude good quality caregiving, methadone is irrelevant2.Poverty plays a large role3.Which co occurs with psychopathology – but I think when considering the literature from BPD this matters probably more so than substance abuse


Quality of Care Giving in Substance Abuse Mothers

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