A methodological pilot: parenting among women in substance abuse treatment.

Original Article Journal of Addictions Nursing & Volume 25 & Number 1, 48Y55 & Copyright B 2014 International Nurses Society on Addictions

A Methodological Pilot Parenting Among Women in Substance Abuse Treatment Linda Lewin, PhD, PMHCNS-BC m Kathleen Farkas, PhD, LISW m Maryam Niazi, RN, MSN, PMHNP-BC

Abstract Background: Mothers who abuse substances are likely to have insecure emotional attachment with their children, placing their children at risk for socialYemotional and psychiatric conditions. Sobriety does not inevitably improve parenting. Objectives: We tested recruitment methods, audiovisual (AV) recording procedures, the protocol for identifying child abuse risk, the coding of motherYchild interactions, and retention of the sample for repeated measures as the first phase in examining motherYchild relational quality of women in substance abuse treatment. Design: This innovative study involved AV recordings to capture the in-vivo motherYchild interactional behaviors that were later coded and analyzed for mean scores on the 64-item ParentYChild Relational Quality Assessment. Repeated measurement was planned during treatment and two months after discharge from treatment. Results: The pilot involved a small sample (n = 11) of motherYchild (G6 years) dyads. Highest and lowest ratings of interaction behaviors were identified. Mothers showed less enthusiasm and creativity but matched their child’s emotional state. The children showed appropriate motor skill items and attachment behaviors. The dyad coding showed less mutual enjoyment between the mother and child. Eight of the participants could not be located for the second measurement despite multiple contact methods. Conclusions: AV recordings capture rich, descriptive information that can be coded for interactional quality analysis. Repeated measurement with this cohort was not feasible, thus needing to assess for additional/more frequent contacts to maintain the sample.

Linda Lewin, PhD, PMHCNS-BC, College of Nursing, Wayne State University, Detroit, Michigan. Kathleen Farkas, PhD, LISW, Mandel Applied Social Sciences, and Maryam Niazi, RN, MSN, PMHNP-BC, School of Nursing, Case Western Reserve University, Cleveland, Ohio. The authors acknowledge funding for this study from the American Psychiatric Nurse Foundation. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Linda Lewin, PhD, PMHCNS-BC, College of Nursing, Wayne State University, 5557 Cass Avenue, Detroit MI 48202. E-mail: [email protected] DOI: 10.1097/JAN.0000000000000017 48

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Keywords: attachment, methodological study, parenting, substance use disorders

INTRODUCTION Women who have young children and have substance use disorders (SUDs) experience increased challenges to parenting (Mayes & Truman, 2002). The effects of women’s substance abuse on their children and on their role as a parent are substantial, including greater risk for the children’s physical, academic, and socialYemotional problems (Conners et al., 2004). A variety of permanent birth defects can occur because of prenatal substance abuse exposure including growth deficiencies, attention deficits, mild-to-moderate cognitive disabilities, and attachment problems as well as other bio-physiological outcomes (McCreight, 1997; Noland et al., 2003). Mothers with a history of SUD may not be prepared to deal with these effects. Among childrearing women aged 18Y49 years, approximately 6.3 million need treatment annually for substance abuse (Substance Abuse and Mental Health Services Administration, 2009), which may distract from their role as parent. The good news is that motherhood, with its attendant feelings of responsibility, is a primary motivator for women to seek substance abuse treatment (ICF International, 2009; Jessup, Humphreys, Brindis, & Lee, 2003). Among women entering substance abuse treatment, 70% have children (Werner, Young, Dennis, & Amatetti, 2007). Nonetheless, entering substance abuse treatment and achieving sobriety do not inevitably improve parenting skill. The lack of improved parenting in mothers may be because of the failure to examine the parentYchild relationship in areas such as emotional availability and caregiving (Fraser, Harris-Britterin, Thakkallapalli, Kurtz-Coxtes, & Martin, 2010; Suchman, Mayes, Conti, Slade, & Rounsaville, 2004). Some clinicians posit that the lack of attention to the importance of relationships and the roles women play as the primary child care providers may contribute to reduced treatment access, given that treatment retention and increased relapse among women who are caring for young children are ongoing challenges (Werner et al., 2007). Substance abuse treatment services that promote parentYchild interaction are stressed by the Child Welfare League of America (Banks, 2001). Consequently, advance practice psychiatric nurses who are clinicians in substance abuse programs need information regarding the specific parentYchild relational behaviors to promote to enhance the emotional quality of the interaction. January/March 2014

Copyright © 2014 International Nurses Society on Addictions. Unauthorized reproduction of this article is prohibited.

There is a paucity of research regarding the emotional quality of the parentYchild relationship in women who are in treatment and initial recovery; thus, this innovative pilot study was initiated to ascertain the appropriate methods for this research. The objectives of this methodological pilot study were to (1) assess the feasibility of recruitment and retention for the repeated measures design, (2) test data collection procedures for audiovisual (AV) recordings; (3) test the protocol for the identification of child abuse risk in this cohort, (4) determine coder agreement for the parentYchild relational instrument, and (5) perform a preliminary examination of the means and ranges of the scores on the parentYchild relational measure. This novel means of capturing organic interactional qualities first required a methodological pilot that will inform the planning of a future study with a larger sample. Review of the Literature Previous, less contemporary studies about mothers who abuse substances indicate that they score higher than other mothers on a wide range of negative parenting behaviors such as poor sensitivity and responsiveness, neglect, harshness, high levels of intrusiveness, and reliance on the use of corporal punishment (Chaffin, Kelleher, & Hollenberg, 1996; Hans, Bernstein, & Henson, 1999; Magura & Laudet, 1996). Self-reported behaviors by mothers with SUD reveal extremes in parenting styles including permissiveness, poor supervision, the use of threats, and intolerance (Suchman & Luthar, 2000). Critically, child maltreatment has been shown to have a strong association in families with parental substance abuse (Ammerman, Kolko, Kirisci, Blackson, & Dawes, 1999) and is a major factor in the loss of legal custody (Center for Substance Abuse Treatment, 2004). More recently, it has been reported that the children of these mothers are at high risk for developmental problems and adolescent substance use (Center for Substance Abuse Treatment, 2005). Of course, there are many other factors, in addition to the impact of negative parenting behaviors, contributing to the risk for developmental problems and substance abuse in children. In-utero exposure and familial history of substance abuse contribute to genetic risks and impoverished environments and ready access to substance create environmental risks. Kendler et al. (2012) found a complex mix of both genetic and familial factors to be associated with substance abuse problems in a large, longitudinal study of adoptees. However, involvement of supportive parents has been shown to moderate the genetic risk for substance use in adolescents highlighting the important focus on the parentYchild relationship (Brody et al., 2009). Mothers with SUD are more likely to have insecure attachment with their children, placing their children at risk for the development of comorbid psychiatric conditions (Fonagy et al., 1996). Bowlby’s (1982) seminal research on attachment showed that the development of secure attachment is impeded during prolonged periods of emotional or physical unavailability (as is the case with SUD). Ainsworth’s pioneering work described the critical necessity of attachment and the dynamic reciprocity between all mothers and their young children (Ainsworth, Journal of Addictions Nursing

1973; Ainsworth, Blehar, Waters, & Wall, 1978). The quality of the mother’s behavior involves sensitivity to her child’s mood and accuracy in responding to a young child’s behavioral cues (Ainsworth, 1969; Ainsworth, Bell, & Stayton, 1971). The mother must balance her vigilance for her child’s safety with promoting the child’s exploration of new situations or objects. Central to this balance is the attachment dimension of cooperation versus interference. In other words, mothers need to know when to interrupt the young child’s ongoing activity to secure safety and when to sit back to promote the child’s continuity for play and discovery. In the specific case of a mother’s prenatal and ongoing SUD, negative interactions between the impaired mother and her young child result in feedback loops, which are reinforced with each exchange. Pajulo, Suchman, Kalland, and Mayes (2006) describe this motherYchild dynamic as one of ‘‘difficult regulatory partners’’ (p. 451). The young child ‘‘ups the ante’’ when the impaired mother does not respond to subtle cues, and the mother becomes more frustrated as her child’s signals become more frequent and disturbing. When parents repeatedly miss their child’s cues, the child eventually stops providing them. The result is disengaged parents with disengaged babies. This parentYchild dyad then has difficulty forming a healthy, appropriate relationship. Children of parents with SUD may be unable to form secure attachments, become mistrustful of others, and have difficulty regulating their own emotions (ICF International, 2009; Stanger et al., 2002). Notwithstanding the shortcomings, parenthood can be a significant motivator in seeking SUD treatment and maintaining sobriety (Tracy & Martin, 2007). Pajulo and colleagues (2006) suggested that fostering parents’ emotional availability, openness, and responsiveness would reduce the negative effects of maternal substance abuse on children. Their work calls for a focus on enhancing parentYchild interactions. Smith (2006) adds further justification for this approach garnered from themes of mothers in SUD treatment groups, including concerns over the lack of family focus in treatment, exclusion of children from the treatment environment, limited family counseling services, and increased substance use when children were removed from their mothers’ custody. Within SUD treatment, typical parenting improvement interventions involve parent education, yet there is little evidence that this cognitively based approach is effective (Suchman et al., 2010). For example, in a randomized clinical trial, Catalano and colleagues (1999) tested a parent training program that was combined with home-based case management for parents on methadone intervention. There was a decline in substance abuse relapse, but there were no differences in family bonding, conflict reduction, or children’s reports of parental involvement. Unfortunately, few treatment programs have been identified that address both women’s substance abuse and concurrent improvement in the quality of the parentYchild relationship (Donohue, Romero, & Hill, 2006). The Mothers and Toddlers Program for 0- to 36-month children (Suchman et al., 2010) and structural ecosystems therapy for over 11 years (Mitrani, McCabe, Robinson, Weiss-Laxer, & Feaster, 2010) are www.journalofaddictionsnursing.com


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currently being investigated for benefits for SUD and HIVpositive women who are parenting. Anecdotally, therapists who participated in the structural ecosystem study found that women were more interested in addressing parenting issues than their own compromised health concerns, thus suggesting that engagement around parenting should be primary (Mitrani et al., 2010). Upon review of current literature, there is little to suggest that empirical description of parentYchild relational quality among women in SUD treatment and recovery has been examined. Therefore, the present innovative approach that captures in-vivo interactional qualities was conducted as a methodological pilot to test recruitment strategies, data collection protocols using AV recordings, risk assessment for child maltreatment, a determination of the coding agreement, and scoring of the interactions as an antecedent to a future study. METHOD Design The study was a single-group, single-clinical-site, repeated measures design collecting data while participants were in substance abuse treatment and 2 months after discharge, living in the community. A repeated measure was chosen to assess change over time and change under different conditions from the point of treatment and after the return to the demands of daily living after treatment. Setting The participants were recruited from a women’s substance abuse treatment program located in an urban Midwestern city. The residential treatment facility was located in a lower-income area of the city and was unique in its structure to admit women and their children. The residential facility was designed with interior, individual suites, and women could elect to have their children reside with them or visit on a scheduled basis. Because of the 24/7 staff coverage in the facility, the county child protective services (CPS) permitted mothers who lost temporary custody to be in residence with their children. Alcohol, cannabis, and cocaine were the dominant substances of abuse or dependence. Most of the residents were represented by minority races and were underemployed or unemployed. Most of the women admitted for treatment were referred by CPS or by a substance abuse clinician. Before admission, the women usually had lived independently or with relatives/friends. The agency services are underwritten by county funds, federal funds, and donations. The women were lodged for an average of 6 weeks. Sample A collaborating clinician from the treatment agency identified women who met the inclusion criteria for the study. These women met for a casual mother’s group on weekends while in residence for treatment. The researchers were invited to attend the mother’s group to share the details of the study and invite participation. Women were enrolled if they were 18 years old or older, with a child who was 6 years old or younger, able to pose questions regarding the research, and had a health sta50


tus that did not require skilled nursing care for any health problems. Women who had an active child maltreatment investigation or who were under no-contact court order were not considered for the study. Instrument The Parent Child Early Relational Assessment (PCERA) scale designed by Clark (2006) was used for coding the interactions captured on the AV recordings of each mother with her child. The theoretical underpinning of the instrument is that maternal affect and behaviors serve as a model of the child’s behavioral and social development. The PCERA has shown both construct and predictive validity and has been used in multiple studies of children aged 2Y60 months or 5 years (Clark, Tluczek, & Gallagher, 2004). Other parentYchild instruments have a narrower child age range and often use frequency counts that do not fully describe the qualitative dynamics of the interaction (Clark, Paulson, & Colin, 1993). Discriminant validity studies using the PCERA have shown differences between groups of parentYchild dyads ranging from high risk to well functioning (Clark, 1999). The internal consistency/reliability of item scores per subscale using Cronbach’s alpha ranges from .78 to .91. Some examples of the interactional elements that have been evaluated with the PCERA include tone of voice, affective interaction, mood, behavioral involvement, activity level, communication, and mutuality. An ordinal, Likert-type scale is used to code each of the variables, with a low score of 1Y2 indicating an area of concern, a score of 3 indicating some concern, and a score of 4Y5 indicating an area of strength. In this study, all of the AV recordings were scored for all 65 PCERA variables. Procedure The study procedures for the protection of human subjects were approved by the institutional review board of the affiliate university. Because of telephone-use restrictions at the treatment facility, all of the women who were interested in participating provided their names to a research team member at the time of the recruitment meeting or to a designated agency staff member to schedule an appointment for the first round of data collection. A plan was developed to retain the participants for the second round of data collection including (a) obtaining the telephone number and address where the participant expected to live after discharge; (b) collecting names, addresses, and telephone numbers of three people who would know where the mother was residing 2 months after discharge; (c) making a follow-up contact within 2 weeks of discharge to confirm a participant’s location; and (d) use of modest incentives to keep research participants interested in the study. Participants from the first round were contacted by postal mail and telephone and via contact individuals for the second data collection appointment. If a participant did not respond to any of the several contact attempts, they were not included in the second data collection. To assure participant confidentiality, the study was introduced during the mothers’ group meetings in their treatment surroundings. Potential participants had the opportunity to January/March 2014


pose questions during the introduction of the study. Next, over a period of 8 months, first-round data for the motherY child relationship were collected using two 5-minute AV recordings, one of free play and one of feeding. At the end of each recording, three standardized, closed-end questions were posed to the mother about the maternal role. The researchers, assistants, and video technician were never alone in a room with a child and did not take the child to the bathroom or change a diaper. In accordance with the study protocol for risk assessment, if child neglect or abuse occurred, a report was made via the agency clinical director to the county CPS. Field notes were kept describing any adverse events or unusual/severe emotional reaction or behavior and submitted to the institutional review board. The AV recordings were coded separately by two members of the research team, and interrater agreement was calculated. Agreement was defined a priori as plus or minus 1 point agreement on the 5-point scale. If any item resulted in less than an 85% agreement, the item was recoded by each of the raters. These items were reviewed and discussed for clarification, and mutual coding was established by verbal agreement. The responses to the qualitative questions were transcribed from the AV recordings in preparation for analysis.

TABLE 1

Demographic Characteristics

Characteristic Mother’s age (years)

Demographics During the pilot period, 11 motherYchild pairs consented and participated in the first round of data collection. The mothers in the study reported their race or ethnicity as African American (6), White (3), Hispanic (1), and mixed (1). The mean age of the mothers was 31 years (range of 23Y43 years), and the mean age of the index child was 27 months (range of newborn to 60 months). The average age of the mothers when they had their first child was 20 years (range of 13Y35 years). Two of the eleven mothers disclosed that they took antidepressants, one mother took mood-stabilizing medications, and none of the mothers indicated that they took antipsychotics or pain medications. Three mothers had current CPS involvement or custody of their children, and five mothers had been investigated but retained custody. Seven women reported that they had been convicted of a misdemeanor or felony since they had turned 18 years old. Most of the women had not finished high school (54%), and only one participant was married/living with a partner (see Table 1). Employment and socioeconomic statuses were not asked of the participants because all of them were in residential, full-time SUD treatment funded through public support and donations. First Objective: Recruitment Procedures The first objective of the investigators was to assess the feasibility of recruitment methods and retention for the repeated measures design with two measurement points. All of the women who met the inclusion criteria and were interested in the study consented and participated in the first round of recordings. The investigators attempted to reach the particiJournal of Addictions Nursing

31 (range: 25Y43)

Self-reported race African American

6 (55)

White

3 (27)

Hispanic

1 (09)

Mixed

1 (09)

Mother’s age at first birth

20 (range: 13Y35)

Mother’s education Less than high school diploma

6 (55)

High school diploma or General Educational Development

3 (27)

Postsecondary

2 (18)

Current CPS involvement/loss of custody

5 (45)

Convicted of a misdemeanor or felony

7 (64)

Not married/divorced Married/living with a partner

FINDINGS

n (%)

Child’s age (months)

10 (92) 1 (09) 27 (range: 0Y60)

pants and their alternative contacts for the second round of data collection, but only three women were located 2Y3 months after their departure from the treatment facility. With this low response/retention rate, the second round of data could not be considered for comparison. Second Objective: Protocol for AV Recording Data Collection Specifically, the investigators tested the feasibility and accuracy of the AV recording procedures of the motherYchild interaction. All of the AV recordings using a high-definition videocamera were of high quality for sound clarity, lighting, width of screen, and zoom function for facial close-ups. A tripod was used to prevent ‘‘pulsing’’ movements caused by handheld recordings and to have a smooth movement horizontally to follow the frequent movements of the young children. A room with ceiling lighting and a large window were sufficient for day-time recordings without creating any shadows. A light pastel scarf was draped under the face of the woman if the clothing she wore did not allow enough contrast to illuminate her facial expressions. Finally, we found that it was not necessary to use an external microphone to capture verbal interactions for tone and content. Third Objective: Assessment of Risk of Child Maltreatment Because of the potential risk for child abuse or neglect that could occur in this cohort of substance addicted women, a protocol with accompanying response script for the identification www.journalofaddictionsnursing.com


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of different levels of child abuse risk was developed for testing during the pilot study. The guide consisted of a three-tiered level of risk including: level 1, motherYchild pair demonstrating distress before interaction; level 2, negative trend in motherY child interaction that would require a pause in recording; and level 3, verbally or physically abusive behavior. The scripted AV recording responses reflected the safety directives for each risk level. There were no instances of child maltreatment risk behaviors at any level by the participating mothers based on the child risk guidelines developed for the study. Fourth Objective: Determine Coding Agreement for the Instrument Before knowing how many motherYchild pairs could be recruited, the investigators had set interrater agreement at 85%. Retrospectively, the investigators found that, if there was a lack of coding agreement on more than one pair, then the agreement rate dropped below the preset level. Consequently, interrater agreement was reset as agreement on 7 of the 11 pairs for each item. With the newer level of agreement, the two raters lacked agreement on 7 of the 65 PCERA items. These items were reviewed and recoded based on discussion and mutual agreement. Fifth Objective: Examine Means and Ranges of the Scores The researchers for this pilot study computed the means and ranges of the scores on the parentYchild relational measure (see Table 2). As expected in a small sample pilot study, the results lacked variability. Nonetheless, some maternal, child, and dyadic PCERA items were highlighted for higher and TABLE 2

ParentYChild Relational Assessment, Select Items: Coding Results

PCERA Interactional Coding

M (range: 1Y5)

lower mean scores. The maternal behaviors ranged from 2.9 to 4.7, child behaviors ranged from 3.4 to 5.0, and dyadic behaviors ranged from 3.2 to 4.9. Maternal behaviors that trended higher were the absence of anger/hostility in tone or behavior (M = 4.7) and the lack of hypomania mood disturbance (M = 4.9). Lower maternal behaviors included only slight evidence of enthusiasm or joie de Vivre (M = 3.2) and minimal creative or novel interaction with her child (M = 3.1). The most positive child behavior in the sample of newborns to 5-year-olds was age appropriate motor competence (M = 4.9), and no negative child behavior was below the level of a strength score. Dyadic strengths were the mother/child state similarity of affect and activity (M = 4.0) and the absence of anger/hostility (M = 4.7) between dyads. The most negative mean score was the dyad’s mutual enjoyment (M = 3.3). Three open-ended questions were asked and recorded based on the PCERA protocol, including the following: (1) Is this a typical day for you and your child? (2) How would you describe yourself as a mother? (3) In the world of all mothers, how would you rate yourself? Two of the mothers indicated that, on the day of data collection, either their child was not well the night before or the child’s twin was not part of the recordings, reflecting their perception that the child was not experiencing a typical day for behavior or mood. In response to the second question, most of the mothers described themselves in positive terms such as ‘‘trying to do better,’’ ‘‘dedicating myself to my child,’’ ‘‘patient,’’ ‘‘making her say her letters and numbers,’’ and ‘‘nurturing.’’ However, several mothers indicated that they were ‘‘frustrated,’’ ‘‘very stressed,’’ or ‘‘not allowed to yell or whoop.’’ In response to question 3, most mothers rated themselves on a 10-point scale, with minimal elaboration on the self-ranking. They rated themselves most often as ‘‘7’’ and would add ‘‘I’m still learning’’ or ‘‘I’d be a 10 with housing and a job.’’ Other descriptors were ‘‘pretty good,’’ ‘‘I meet my child’s needs,’’ ‘‘I’m open to advice,’’ and ‘‘I offer as much love as I can but I’m trying to straighten my life out.’’ Another participant mother stated that she was ‘‘a 5 as an addict and a 9 as a typical mom.’’

Highest mother behaviors Absence of anger

4.7

Lack of hypomania

4.9

Lowest mother behaviors Enthusiasm

3.2

Creative interaction

3.1

Highest child behavior Motor competence

4.9

Lowest child behaviors

None G 3.5

Highest dyadic behaviors Mother/child state similarity

4.0

Absence of anger

4.7

Lowest dyadic behaviors Mutual enjoyment 52


3.3

DISCUSSION The findings of this pilot study informed and directed the planning for a subsequent, larger-sample, two-site study, thus saving time, effort and cost (Connelly, 2008). The investigators discovered several procedural impediments from the pilot study that were identified in our findings, primarily the meager retention of the participants for a second measurement after discharge from the facility, the a priori minimum level of interrater agreement, and the variability of PCERA scores. Both the interrater agreement and data variability limitations can be addressed by the recruitment of a larger, multi-site sample. The first objective of the pilot was to ascertain the ease of recruitment and retention. The treatment facility can house up to 60 residents and their children (aged 0Y17 years) for SUD treatment and after-care. Initial recruitment was primarily aimed at women who attended the weekly mothers’ discussion group within the treatment program. If eligible January/March 2014


women did not attend the weekly group, then the recruiting information was limited to flyers that were posted in the facility. Recruitment was nearly effortless among the mothers’ group attendees as 100% of the dyads who were interested in the study consented to participate; however, it took 6 months to accumulate a sample of 11 motherYchild pairs for the first round of data collection. No agency data were available regarding the number of children who were age eligible during the year of the study. Significantly, retention of this vulnerable cohort merely 2 months after discharge from treatment was arduous and unproductive. Obtaining multiple names of people who would know the location of a participant, using postal mail and telephone contacts, offering compensation for child care and transportation, and a higher value compensation for the participant’s time for the second data collection produced only three responses from the sample of 11 women. The remaining eight study participants could not be found. Residential treatment settings provide an ideal place for data collection; however, the time immediately after release from treatment can be chaotic and fluid. It is hypothesized that the mothers who could not be reached to reschedule the second data collection lacked stability of housing and a communication network, either through their own telephones and mailing addresses or those of their listed contacts. Their best estimates of their situations after release were not reliable. This lack of a housing address or telephone contact is consistent with a recent study of other SUD participants where it was found that addiction treatment was inversely associated with housing stability (Palepu, Marshall, Lai, Wood, & Kerr, 2010). Planning for stable housing and living conditions before discharge is critical and can be a motivator in sustaining recovery (Tsemberis, Gulcur, & Nakae, 2004). Furthermore, other investigators found that practical resource needs such as housing, child care, counseling and employment were relevant and predictive of relapse (Castellani, Wedgeworth, Wooton, & Rugle, 1997; Walton, Blow, Bingham, & Chermack, 2003). Thus, inclusion of information about the stability of living situations after discharge should be considered as a vital part of repeated measure research designs. Frequent contact with women recently released into the community from residential treatment may also boost tracking success. More generous research funds than what were available for this pilot study can provide prepaid, disposable cell phones for each participant to maintain more frequent contact including text message reminders of data collection appointments. Concerns about the legitimacy of telephone use in this cohort must be addressed in the context of the ethical principle of autonomy and trust. The second objective of the study included testing the AV recording procedures. This process was critical to become familiar with the recording equipment and to capture data without loss of interaction details. Interactional data captured by the AV recording procedures were precise and could be viewed multiple times for accurate coding and resolution of interrater agreement concerns. AV recording of macro (motor behavior) and micro (eye contact) behaviors and sounds, Journal of Addictions Nursing

along with vocalizations (as in the case of preverbal children), are most useful in capturing the in-vivo relational qualities of mother and child. The use of the zoom-in/out function was particularly important for women who were holding infants, allowing recording of both facial features and full-body response by the infant. Data collection by this means is considered ethically acceptable when fully described in the consent, and the actual experience does not significantly affect the participant behavior or stress (Coleman, 2000; Themessl-Huber et al., 2008). The investigators recommend a digital camera that is capable of self-adjusting settings for sound and focus, along with a tripod that is equipped with a swivel head for panning and tilting. Protective carrying cases for the camera and tripod with shoulder straps, along with service warranties, are a good investment to protect the long-term use of the equipment. Objective 3 of the study tested the usefulness of the threetiered risk guide developed by the principal investigator. In this high-risk cohort, the data collectors had the responsibility of monitoring any interactional behaviors that could potentially lead to psychological or physical harm of the child. However, confidentiality was an obligation; thus, the threetiered risk guide was designed to identify early indicators of a negative trend in the interaction as well as to interrupt the process and provide a brief interventional script before any harm. The highest tier, reflecting an actual event of harm, was a script that reflected the language in the informed consent document for the necessity of breaking confidentiality and reporting the event to protective services. During the pilot study, there was no need to implement any of the three tiers. The researchers were satisfied with the current sensitivity of the three-tiered guide and script; thus, it can be useful in a protocol for a larger sample study. Our fourth objective was to determine and establish high agreement on the coding of the motherYchild behaviors. Interrater agreement is important to assure that equivalence of coder judgments is enacted (Burns, Grove, & Mohnkern, 2009). The seven PCERA items that had the lowest agreement provoked discussion between the two coders and resulted in a greater clarity of behavior ratings. In the future, interrater agreement will be calculated and modified as needed for the first five recordings and every seventh recording thereafter. Agreement that is calculated at less than the minimum should result in a joint recoding and discussion for mutual agreement on low-agreement items. Our fifth and final objective was to calculate mean scores of the PCERA to identify higher and lower relational behavior. This small sample lacked statistical variability that can be addressed in a larger sample study. In response to the PCERA protocol questions, the mothers described their parenting skills as having improved since entering residential treatment, and they acknowledged the various contrasts between their parenting affected by substance abuse and clean/sober parenting. The study procedures followed the PCERA protocol to elicit the mothers’ natural observations and perspectives in close proximity of the interaction with their child. The research team www.journalofaddictionsnursing.com


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was satisfied with the use of the PCERA for the detailed description of coding and its applicability to coding the relational quality between mother and child and plans to use it in a larger sample study. Equivalent empirical comparisons of parenting quality in control and study samples have been described in earlier literature. Goodman and Brumley (1990) found that mothers with schizophrenia or depression showed lower quality and greater variability in parenting quality than well women. Interestingly, the mother’s parenting practices, and not the disorder, accounted for the child’s social competence. Similarly, Burns, Chethik, Burns, and Clark (1997) compared the standardized sample used in the development of the PCERA and cocaine-abusing mothers. The cocaine-abusing mothers showed more rigidity, overcontrol, limited emotional involvement, and less responsivity in their interactions compared with the standardized sample. The research team gained procedural experience and a greater understanding about conducting descriptive research with this understudied area of parenting by women in substance abuse treatment. The methodological pilot study was critical in the planning of descriptive and interventional testing. Limitations The small sample of the pilot study limited any statistical significance; therefore, any value is restricted to the methodological objectives. The research participants were informed that the motherYchild interactional tasks would be recorded as part of their informed consent considerations. The participants’ knowledge of the recordings may have influenced their behavior and responses; thus, the interactions may not have been a typical depiction. However, the young children could not cognitively ascertain socially acceptable behavior depicted for the recordings and more likely behaved in naturalistic ways. In addition, mothers who had never employed particular interactional qualities with their child would have been unable to show them for the recordings. With the small sample, it was not possible to conclusively tease out the prospective effects of SUD on parenting. In other words, does weaker parenting co-occur with substance abuse, or is weaker parenting the outcome of SUD? The question poses a research objective that could be implemented in a much larger sample that examines the parenting history of women whose substance abuse was initiated before and after the birth of women’s first children. Although the examination of SUD influence on parenting is an intriguing study purpose, it was beyond the scope of this methodological pilot study. CONCLUSIONS The key findings in this methodological pilot study are that a large number of discrete, complex behaviors between mother and young child can be captured using the procedures described. However, a significant lesson learned was that repeated measures design for this cohort was not feasible or productive and that more emphasis and resources on tracking and communication efforts are required. Additional strategies such as more frequent contacts, such as text messaging 54


and additional incentives, should be considered to retain participants who commonly experience unstable housing and contact networks. A fully powered study is likely to produce greater variability, leading to the identification of statistically significant behaviors that could be identified for an intervention study. The importance of motherhood to the self-concept of women with SUD and how this might be used in the development of an intervention study is most desirable. Further research will compare current intervention options with those that aim to enhance the emotional quality of the motherYchild relationship and guide specific parenting behaviors in need of modification and reinforcement. REFERENCES Ainsworth, M. (1973). The development of infant-mother attachment. In B. M. Caldwell & H. N. Ricciuti (Eds.), Review of child development research (vol. 3, pp. 1Y94). Chicago, CA: University of Chicago Press. Ainsworth, M. D. (1969). Object relations, dependency, and attachment: A theoretical review of the infant-mother relationship. Child Development, 40, 969Y1025. Ainsworth, M. D. S., Bell, S. M., & Stayton, D. J. (1971). Individual differences in strange-situational behavior of one-year-olds. In H. R. Schaffer (Ed.), The origins of human social relations (pp. 17Y57). New York, NY: Academic Press. Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum Associates. Ammerman, R., Kolko, D., Kirisci, L., Blackson, T., & Dawes, M. (1999). Child abuse potential in parents with histories of substance use disorder. Child Abuse & Neglect, 23, 1225Y1238. Banks, H. (Ed.). (2001). Alcohol, other drugs, & child welfare. Washington, DC: Child Welfare League of America. Bowlby, J. (1982). Attachment and loss: Vol. 1 attachment (2nd ed.). New York, NY: Basic Books. Brody, G., Beach, S., Philbert, R., Chen, Y., Lei, M., Murry, V., & Brown, A. (2009). Parenting moderated a genetic vulnerability factor in longitudinal vulnerability factors in youth’s substance use. Journal of Consulting and Clinical Psychology, 77(1), 1Y11. Burns, K., Chethik, L., Burns, W., & Clark, R. (1997). The early relationship of drug abusing mothers and their infants: An assessment at eight to twelve months of age. Journal of Clinical Psychology, 53(30), 279Y287. Burns, N., & Grove, S. K., & Mohnkern, S. (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence (6th ed.). Philadelphia, PA: Elsevier. Castellani, B., Wedgeworth, R., Wooton, E., & Rugle, L. (1997). A bidirectional theory of addiction: examining coping and the factors related to substance relapse. Addictive Behaviors, 22, 139Y144. Catalano, R., Gainey, R., Fleming, C., Haggerty, K., & Johnson, N. (1999). An experimental intervention with families of substance abusers: One-year follow-up of the focus on families project. Addiction, 94, 241Y254. Center for Substance Abuse Treatment. (2004). Substance abuse treatment for persons with child abuse and neglect issues. Treatment improvement protocol (TIP). Series 36. DHHS Publication No. (SMA) 04 Y3923. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. (2005). Substance abuse treatment and family therapy. Treatment improvement protocol (TIP). Series 39. DHHS Publication No. (SMA) 04 Y3957. Rockville, MD: Substance Abuse and Mental Health Services Administration. Chaffin, M., Kelleher, K., & Hollenberg, J. (1996). Onset of physical abuse and neglect: Psychiatric, substance abuse, and social risk factors from prospective community data. Child Abuse & Neglect, 20, 191Y203. Clark, R. (2006). The parentYchild early relational assessment: Instrument and manual. Madison, WI: University of Wisconsin Medical School, Department of Psychiatry. January/March 2014


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Substance abuse and parenting among African American mothers of adolescents.

Prevalence of substance abuse in pregnancy among Danish women.

Parenting Efficacy and Support in Mothers With Dual Disorders in a Substance Abuse Treatment Program.

Differential responsiveness to a parenting intervention for mothers in substance abuse treatment.

Methodological issues in genetic studies of human substance abuse.

Substance abuse among psychiatric inpatients.

Substance abuse among older adults.

Substance abuse among adolescents with chronic mental illnesses: a pilot study of descriptive and differentiating features.

dependence treatment: a European perspective.

Substance abuse-specific knowledge transfer or loss? Treatment program turnover versus professional turnover among substance abuse clinicians.

Trauma symptoms for men and women in substance abuse treatment: a latent transition analysis.

John Henryism Active Coping as a Cultural Correlate of Substance Abuse Treatment Participation Among African American Women.

A quantitative exploratory evaluation of the circle of security-parenting program with mothers in residential substance-abuse treatment.

Gender abuse, depressive symptoms, and substance use among transgender women: a 3-year prospective study.

What is substance abuse? And should we screen all pregnant women for substance abuse?

Substance use among lesbian, gay, and bisexual clients entering substance abuse treatment: Comparisons to heterosexual clients.

Job satisfaction among substance abuse prevention personnel.

Substance abuse among nurses at teaching hospitals.

Epidemiology of substance abuse among Latinos.

Substance Abuse Among Blacks Across the Diaspora.

Heterosexual Anal Sex Among Men and Women in Substance Abuse Treatment: Secondary Analysis of Two Gender-Specific HIV-Prevention Trials.

Families parenting adolescents with substance abuse--recovering the mother's voice: a narrative literature review.

Human growth hormone: a new substance of abuse among adolescents?

Substance abuse among veterans with a diagnosis of schizophrenia.