Integrated programs for mothers with substance abuse issues and their children: A systematic review of studies reporting on child outcomes☆
Introduction
Maternal substance abuse is a serious problem for the child welfare system. Estimates suggest that 50–80% of child welfare cases involve a parent who abuses alcohol or other drugs and mothers make up the majority of substance-abusing parents in the child welfare system (SAMHSA, 2002, US Department of Health and Human Services, 1999). In the USA, 59% of the adults in substance abuse programs are parents (i.e., over 1 million of the 1.84 million in treatment) and 27% (294,000) have had 1 or more children removed by child welfare services (SAMHSA, 2002). Other estimates suggest that up to 70% of women in substance abuse treatment have children (US Department of Health and Human Services, 1999). These circumstances have serious implications for child welfare, health, and development and represent considerable human and financial burden to society.
Rates of substance abuse in women have been increasing (Greenfield, 2002) and substance abuse in women also is associated with a unique constellation of risk factors and needs, including greater vulnerability to adverse physiological consequences than men, greater prevalence of mental health problems, histories of physical or sexual abuse, serious medical problems, poor nutrition, relationship problems (including domestic violence), and deficits in social support (Hans, 1999, Hernandez-Avila et al., 2004). The unique risk factors and presenting needs of women have resulted in the development of women-specific comprehensive treatment models (Greenfield, 2002). However, in addition to having gender-specific needs, women with substance abuse issues also have unique needs as mothers.
Use of alcohol and other drugs during pregnancy can have profound effects on child health and development. Children born to women who used substances during pregnancy are at greater risk for prematurity, impaired physical growth and development, and physical and mental health problems (Barnard & McKeganey, 2004). The postnatal environment of children born to women with substance abuse issues also puts them at high risk for poor outcomes. Research has shown that women who abuse substances may have difficulties providing stable, nurturing environments for their children compounded by challenging life circumstances, including severe economic and social problems, such as lack of affordable housing and homelessness (Kelley, 1998). Maternal substance abuse has been associated with child neglect and abuse (Dunn et al., 2002) and the living conditions of children of women who abuse substances put them at high risk for family disruption, exposure to violence, and poor physical, academic, and socio-emotional outcomes (Conners et al., 2003). In 1 study of preschool age children of mothers with substance abuse issues, cognitive limitations were diagnosed in 69%, emotional or behavioral problems in 16%, and medical problems in 83% (Shulman, Shapira, & Hirshfield, 2000). At school-age, children of women who abuse substances have higher rates of emotional and behavioral problems than other children (Wilens, Biederman, Kiely, Bredin, & Spencer, 1995) and, in adolescence, are more likely to have a major psychiatric disorder (65%; Luthar, Cushing, Merikangas, & Rounsaville, 1998) and use alcohol and other drugs themselves (Legrand, Iacono, & McGue, 2005).
As maternal substance use is a growing problem for the child welfare system and society in general, there is an urgent need to identify effective interventions. Treatment for mothers with substance abuse issues and their children may represent an important opportunity for breaking the intergenerational cycle of addiction and dysfunction, improving child outcomes, and reducing costs (in terms of foster care placement, etc.). However, women with substance abuse issues report difficulties using conventional systems of care (for reasons including fear of losing custody of children, guilt, stigma, and lack of transportation), and request comprehensive services provided in a caring, “one-stop” setting (Howell & Chasnoff, 1999). Given the barriers, risks, and outcome implications, researchers, clinicians, and policy makers recommend that substance abuse treatment programs address women's needs as well as their children's needs through comprehensive, integrated services in centralized settings for both women and children (e.g., Howell & Chasnoff, 1999). This recognition has resulted in the development of numerous integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services), both residential and outpatient. Integrated residential programs or “therapeutic communities” offer long-term (15–18 months) treatment services to women and their children. Both types of programs typically are comprehensive and include group and individual addiction treatment, maternal mental health services, trauma treatment, parenting education and counseling, life skills training, prenatal education, medical and nutrition services, education and employment assistance, child care, children's services, and aftercare.
To date, no systematic reviews of studies of child outcomes of integrated programs have been conducted. Gender specific (i.e., women only) substance use treatment was examined in 1 systematic review and 1 meta-analysis. In their systematic review of 38 studies, Ashley, Marsden, and Brady (2003) found that programs with prenatal care or child care were associated with improved outcomes (substance use, mental health, birth outcomes, employment, and health). Similarly, in their meta-analysis, Orwin, Francisco, and Bernichon (2001) concluded that enhancing women-only addiction treatment programs with prenatal care or therapeutic child care added value above and beyond the effects of standard women-only programs. Neither of these reviews specifically focused on integrated programs or examined child outcomes.
We examined the impact of integrated programs on child outcomes (child development, growth, and emotional and behavioral functioning) in a systematic review of relevant studies. The specific research questions guiding this systematic review were: (1) What is the impact of integrated programs on child outcomes from intake to post-test?; (2) Are integrated programs more effective than no treatment in improving outcomes for children?; and (3) Are integrated programs more effective than non-integrated programs in improving outcomes for children?
Section snippets
Information sources and literature search
We used 3 main strategies to identify outcome studies of intervention programs for women with substance abuse issues and their children: online bibliographic database searches, checking printed sources, and requests to researchers (cf., Rosenthal, 1991). First, we searched relevant bibliographic databases (PsycINFO, MedLine, PubMed, Web of Science, EMBASE, Proquest Dissertations, Sociological Abstracts, and CINAHL) for studies published in English from 1990 to May 2011, using a subject heading
Study selection
In total, 328 studies were retrieved and coded for eligibility. Using the eligibility criteria, we excluded 63 studies because the study design was not randomized, quasi-experimental, or cohort and 50 because participants were not pregnant or parenting. In addition, 41 had no quantitative data on maternal or child outcomes, 27 had no substance use treatment, 16 had no pregnancy, parenting, or child service, 6 included men, and 5 included participants without a substance use problem at baseline.
Discussion
The purpose of this systematic review was to examine the effects of integrated treatment programs on child outcomes, guided by 3 research questions which we address below.
Conclusion
The findings from this systematic review suggest that integrated programs for women with substance abuse issues and their children are associated with positive impacts on child development, growth, and emotional and behavioral functioning. These findings are encouraging in terms of the preventive potential for breaking the cycle of addiction, dysfunctional parenting, and poor outcomes for many vulnerable children. Consistent with the recommendations for research synthesis of Cooper, Hedges, and
Acknowledgment
The authors are grateful to research assistants, Jacky Chan, Joyce Li, and Jennifer Liu.
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The Canadian Institutes for Health Research (CIHR) provided funding for this project.