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Not all such approaches are successful, however. A Cochrane review assessing the impact specifically of parent-infant psychotherapy versus control or an alternative intervention found no significant effects of the psychotherapy on maternal depression or the mother-child dyad Barlow et al. With the advent of primary care medical homes and the resultant integration of physical, mental, and behavioral health care, there has been growing interest in incorporating parenting interventions and support into primary care settings.

This may be a particularly effective way of diagnosing and addressing parental mental health issues. Parents may be more willing to seek health care for their children than for themselves, but during pediatric visits, health care providers may identify a parent who would benefit from mental health treatment Nicholson and Clayfield, Screening adults for depression in primary care settings with the capacity to provide accurate diagnosis, effective treatment, and follow-up is endorsed by the U.

Preventive Services Task Force Models of stepped collaborative care entail screening for and identifying depression in primary care settings and providing straightforward care in those locations while referring patients with more severe or resistant illness to mental health specialists Dennis, Additional primary prevention programs for parental depression have focused on the period from conception through age 5, although most address parents with infants rather than those with toddlers Bee et al.

Selective primary prevention of depression among parents has been tested most frequently in the perinatal period, with most programs targeting high-risk groups, such as mothers with preterm infants or those at increased risk for postpartum depression Ammerman et al.


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The perinatal period appears to be an effective time to reach a broad population of parents. Home visiting programs discussed in detail in Chapter 4 serve parents with high rates of depression, interpersonal trauma, and PTSD, yet less than. Early studies examining the mental health benefits of home visiting interventions for parents had mixed results, but the results of more recent studies have been positive.

In recent studies, for example, home visiting that includes psychotherapy for mothers has been found to improve depression, and as depression improves, so do many measures of parenting Ammerman et al. A randomized controlled trial enrolled women in home visiting programs who were identified as being at risk for perinatal depression Tandon et al. The intervention consisted of six 2-hour group sessions focused on cognitive-behavioral therapy, with skills being reinforced during regular home visits.

At 6-month follow-up, 15 percent of mothers in the intervention group versus 32 percent of the control mothers had experienced an episode of major depression Tandon et al. In a randomized trial of the Building Healthy Children Collaborative, there was no difference in rate of referral to child protective services for mothers who received mental health services as part of home visits and women in a comparison group who did not receive such services; in both groups, almost all mothers avoided referral to child protective services Paradis et al.

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There also have been efforts to help parents with children in center-based care. In a randomized controlled trial of depressed mothers who had infants and toddlers in Early Head Start, investigators tested interpersonal therapy combined with parenting enhancement training versus just treatment for the depression Beeber et al.

Both groups had a significant improvement in depression scores, but only the group with parent training showed enhanced parent-child interaction skills. Beardslee and colleagues describe a nonrandomized, multiyear, multicomponent pilot intervention with parents, staff, and administration in an Early Head Start program serving up to children a year. The intervention, Family Connections, was intended to help staff with strategies for addressing mental health problems in the families they served.

The program, which was provided to all the families, not just those identified as suffering from depression, utilized widespread education of staff and parents and a parent support group. It resulted in improved parent self-reported parenting knowledge and social support and increased parent engagement with the center.

Other approaches have been tried in public health settings. Both interventions improved child mental health symptoms and behaviors. Family Talk utilizes manual-based psychoeducation prevention strategies. One study of 93 families with. While parents with brief or time-limited mental health problems can benefit from brief interventions, those with severe mental illness or more complex mental health disorders are likely to need ongoing support and crisis intervention services.

Unfortunately, interventions to support and strengthen parenting for parents with severe mental illness have typically not been rigorously evaluated using the types of well-designed randomized controlled trials used to test other parenting interventions described in this report, and this is an identified area of need Schrank et al. Shrank and colleagues conducted a systematic review of parenting studies involving parents who had severe mental illness psychosis or bipolar disorder and at least one child between the ages of The review included a heterogeneous range of interventions, and child outcomes were evaluated.

Four of six randomized controlled trials included in the review showed significant benefits from the interventions, which included intensive home visits, parenting lectures, clinician counseling, and Online Triple P; the lower-quality studies showed mixed results. A 3-year observational study of mothers with severe mental illness with children ages demonstrated that over time, as serious symptoms remitted, parents became more nurturing, raising the hope that treatment could lead to improved child outcomes Kahng et al. A meta-analysis of a variety of parenting interventions found a medium to large effect size in improving short-term parent mental health but noted that these benefits may wane over time, again emphasizing the need for longer and more enduring programs Bee et al.

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One approach for parents with severe mental illness that appears to be promising is to provide parenting interventions during intensive outpatient treatment or inpatient treatment for mental health crises Krumm et al. A few hospitals in the United States many more in Europe and Australia have mother-baby mental health units where the baby can stay with the mother while she is hospitalized. A newer observational study in the United Kingdom using a video feedback intervention found that between the time of admission and discharge, mothers with schizophrenia, severe depression, and mania became more sensitive and less unresponsive, and their infants became more cooperative and less passive Kenny et al.

Notably, mothers at discharge had better outcomes on all parenting measures than both a comparison group of nonhospitalized mothers with mental illness of comparable severity and a group of mothers without mental illness in the community. Interventions and treatment for parents with mental illness have been found to significantly reduce the risk of children developing the same mental health problems as well as behavior challenges. A meta-analysis included 1, children in 13 randomized controlled trials of interventions with cognitive, behavioral, or psychoeducational elements for parents with a variety of mental illnesses and substance use problems Siegenthaler et al.

Given the enormous complexity of comorbidities and varieties of presentation in mental illness, sorting out which risks to children derive from parental mental illness and which should be attributed to other stressors is challenging. Doing so is critical, however, for identifying the best strategies for helping families and in considering interventions at both the micro and macro levels.

For example, many parents living with severe mental illness will need support in learning parenting knowledge, attitudes, and practices, specifically in understanding normal child development and milestones and how to provide emotional support for their children. They, like all parents, may also benefit from training in such skills as getting children to have a consistent bedtime routine, feeding them, administering nonphysical discipline, and providing emotional support Nicholson and Henry, ; Stepp et al.

Mothers living with severe mental illness themselves have identified generic parenting issues for which they may need help—both in accessing essential resources and in developing critical parenting skills Nicholson and Henry, Mental illnesses include a wide range of conditions.

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One mother may have severe depression and struggle with lifelong, recurrent episodes, while another may have a single episode of mild postpartum depression. One disorder may cause symptoms that make it difficult to recognize the emo-. Even a single diagnosis can manifest with different symptoms and severity at different stages of the illness, and the illness itself can lead to complications. Parents with severe or recurrent illness also may face separation from their children due to hospitalization or temporary or permanent loss of custody, which can impact parental self-efficacy as well as attachment Gearing et al.

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Thus it is important for programs to tailor services to the individual needs of parents. Programs that offer service coordination are likely to be effective for parents with mental illness who face other adversities as well, such as poverty, family violence, housing instability, and substance abuse. Providers and policy makers also need to be mindful of the multiple layers of risk these co-occurring conditions pose to families, since childhood outcomes will be affected by far more than the parenting behaviors or knowledge targeted by many programs.

Like mental health conditions, substance use and abuse can affect parenting attitudes and practices, as well as engagement and retention in parenting programs. It has been estimated that nearly 22 million Americans have a substance use disorder Center for Behavioral Health Statistics and Quality, Yet in , only 4. Moreover, both research and clinical practice have seen little integration of child development and parenting with addiction prevention and treatment. Most studies on substance abuse to date have measured mainly retention in treatment and reduction in maternal substance use as the primary outcomes, with less attention to parenting and work with children Finkelstein, , ; Nicholson et al.

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Abuse of alcohol and drugs can impact parenting in multiple ways. Potential neonatal effects include prematurity and low birth weight; greater reactivity to stress; increased arousal; higher irritability and restlessness; disordered sleep and feeding; tremulousness, high-pitched cry, and startled response; difficulties with sensory integration, such as abnormal responses to light, visual stimuli, and sounds; and hyperactivity Iqbal et al.

Department of Health and Human Services, a. An infant who cannot regulate sleep, wakefulness, or stress is therefore often partnered with a mother who has. Research has recently combined the neurobiology of addiction with the neurobiology of parenting, and has examined how the disregulation of the stress-reward neural circuits in addiction may impact the capacity to parent Rutherford et al.

It is well documented that increases in stress result in increases in cravings and substance use Sinha, More specifically, the rewarding value of drugs for a substance-dependent individual comes from ameliorating withdrawal and other stressful situations, and this value may diminish biochemically the rewarding and pleasurable aspects of parenting Rutherford et al.

Oxytocin motivates social behavior by stimulating a reward response to proximity and social interaction and has been shown to increase significantly in both mother and infant during periods of close contact and breastfeeding Strathearn et al. Substance abuse interferes with this process. For example, cocaine specifically coopts this neuropathway by decreasing the production of oxytocin and thereby making maternal care less rewarding for a cocaine user Elliott et al.

Dopamine operates similarly: it rewards social behavior and regulates the production of stress-response chemicals.

From a neurobiological perspective, therefore, the motivation to engage with and respond to infants may be compromised in the presence of addiction, and this diminished motivation may result in part from infant signals holding less reward value Rutherford et al.

In addition, the increased stress inherent in the parenting role may increase cravings, drug-seeking behaviors, and relapse to substance use Rutherford et al. From this limited sample, studies have described a range of parenting deficits and consequences, sometimes associated with specific drugs including alcohol , as well as the amount, frequency and duration of use.

Parents may become preoccupied by drug cravings and drug-seeking behaviors, which in turn may lead to physical absences and multiple disruptions in parenting. Further complicating this picture is that all too frequently, the substance-dependent mother has herself been a victim of violence and abuse. High levels of trauma history and moderate to high levels of PTSD diagnosis co-occur among both men and women with substance abuse disorders Back et al. Women whose childhood history includes sexual abuse are significantly more likely than women without such a history to report substance use and abuse, as well as depression, anxiety, and other mental health problems Camp and Finkelstein, Although prenatal substance exposure and early mother-child interactions characterized by intoxication and withdrawal have independent affects, it is the cumulative risk of chemical, psychological, and environmental disturbances related to substance abuse disorders that interferes with parenting and child development Huxley and Foulger, ; Mayes and Truman, These secondary risk factors are amenable to early intervention, identification, and comprehensive treatment modalities, offering an avenue for improved outcomes for both mother and child Barnard and McKeganey, Indeed, childrearing conditions appear to greatly outweigh substance abuse in predicting adolescent outcomes for drug-exposed children Fisher et al.

The result too often is that individuals suffering from addiction are excluded from community programs, as well as research and evaluation studies Camp and Finkelstein, ; U. Department of Health and Human Services, This exclusion includes home visiting programs, which may screen out parents who use alcohol and drugs. Department of Health and Human Services, b.

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Substance abuse can be successfully treated. However, while there is good reason to believe that decreased substance use should lead to improved parenting, there have been no experimental evaluations of whether successful treatment of substance abuse disorders, in and of itself, leads to better parenting. Described below are interventions for substance abuse that include a specific focus on parenting.

The literature describes a number of specific residential treatment programs for mothers with their children. The majority of studies report positive parent and child outcomes using pre-post evaluation designs Allen and Larson, ; Conners et al. Data on 1, women showed positive results, including an infant mortality rate 57 percent lower than that in the general population.

Seventy-five percent of 97 mothers at one site reported improved relationships with their children and learned better stress coping skills Clark, In response to high rates of nonviolent drug-related arrests in the early s, the United States began utilizing drug courts as an alternative to traditional sentencing procedures.

These courts often mandate treatment for substance abuse disorders, frequent drug testing, and periodic court appearances for status hearings Mitchell et al. As of , nearly 3, drug courts were operating in the United States National Institute of Justice, An expansion of the adult drug court model, family treatment drug courts FTDCs were created as an alternative pathway to reunification in child protective cases.

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Parental substance abuse is one of five recognized risk factors for involvement in the child welfare system; once child protective services are involved, children of parents with substance abuse disorders tend to stay in the system longer and spend more time out of their home of origin Child Welfare Information Gateway, The aim of FTDCs is to combat these trends by giving parents with these disorders access to treatment, accountability, support, and a system of structured rewards and sanctions aimed at their ultimately regaining full custody of their children.

One large-scale outcome study compared families served through three FTDCs with a matched control group of more than 1, families with substance abuse issues who received traditional child welfare services. This study found that the FTDC mothers were more likely to enter treatment, entered treatment more quickly, and were twice as likely to complete at least one treatment relative to the control group.

Also, children of mothers who participated in FTDCs were more likely than children in the control group to be reunited with their mothers Worcel et al.