Alison Niccols

Fetal alcohol syndrome and the developing socio-emotional brain

Fetal alcohol syndrome (FAS) is currently recognized as the most common known cause of mental retardation, affecting from 1 to 7 per 1000 live-born infants. Individuals with FAS suffer from changes in brain structure, cognitive impairments, and behavior problems. Researchers investigating neuropsychological functioning have identified deficits in learning, memory, executive functioning, hyperactivity, impulsivity, and poor communication and social skills in individuals with FAS and fetal alcohol effects (FAE). Investigators using autopsy and brain imaging methods have identified microcephaly and structural abnormalities in various regions of the brain (including the basal ganglia, corpus callosum, cerebellum, and hippocampus) that may account for the neuropsychological deficits. Results of studies using newer brain imaging and analytic techniques have indicated specific alterations (i.e., displacements in the corpus callosum, increased gray matter density in the perisylvian regions, altered gray matter asymmetry, and disproportionate reductions in the frontal lobes) in the brains of individuals prenatally exposed to alcohol, and their relations with brain function. Future research, including using animal models, could help inform our knowledge of brain-behavior relations in the context of prenatal alcohol exposure, and assist with early identification and intervention.

Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes

BackgroundIntegrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, dysfunctional parenting, and poor outcomes for mothers and children, yet there has been no systematic review of studies of parenting outcomes.ObjectivesAs part of larger systematic review to examine the effectiveness of integrated programs for mothers with substance abuse issues, we performed a systematic review of studies published from 1990 to 2011 with data on parenting outcomes.MethodsLiterature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline, the treatment program included at least one specific substance use treatment and at least one parenting or child service, and there were quantitative data on parenting outcomes. We summarized data on parenting skills and capacity outcomes.ResultsThere were 24 cohort studies, 3 quasi-experimental studies, and 4 randomized trials. In the three randomized trials comparing integrated programs to addiction treatment-as-usual (N = 419), most improvements in parenting skills favored integrated programs and most effect sizes indicated that this advantage was small, d s = -0.02 to 0.94. Results for child protection services involvement did not differ by group. In the three studies that examined factors associated with treatment effects, parenting improvements were associated with attachment-based parenting interventions, children residing in the treatment facility, and improvements in maternal mental health.ConclusionsThis is the first systematic review of studies evaluating the effectiveness of integrated programs on parenting. The limited available evidence supports integrated programs, as findings suggest that they are associated with improvements in parenting skills. However, more research is required comparing integrated programs to addiction treatment-as-usual. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the parenting needs of women with substance abuse issues.

Integrated programs for mothers with substance abuse issues and their children: A systematic review of studies reporting on child outcomes

BACKGROUND Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children. OBJECTIVES To examine the impact and effects of integrated programs for women with substance abuse issues and their children, we performed a systematic review of studies published from 1990 to 2011. METHODS Literature search strategies included online bibliographic database searches, checking printed sources, and requests to researchers. Studies were included if all participants were mothers with substance abuse problems at baseline; the treatment program included at least 1 specific substance use treatment and at least 1 parenting or child treatment service; the study design was randomized, quasi-experimental, or cohort; and there were quantitative data on child outcomes. We summarized data on child development, growth, and emotional and behavioral outcomes. RESULTS Thirteen studies (2 randomized trials, 3 quasi-experimental studies, 8 cohort studies; N=775 children) were included in the review. Most studies using pre-post design indicated improvements in child development (with small to large effects, ds=0.007-1.132) and emotional and behavioral functioning (with most available effect sizes being large, ds=0.652-1.132). Comparison group studies revealed higher scores for infants of women in integrated programs than those not in treatment, with regard to development and most growth parameters (length, weight, and head circumference; with all available effect sizes being large, ds=1.16-2.48). In studies comparing integrated to non-integrated programs, most improvements in emotional and behavioral functioning favored integrated programs and, where available, most effect sizes indicated that this advantage was small (ds=0.22-0.45). CONCLUSIONS Available evidence supports integrated programs, as findings suggest that they are associated with improvements in child development, growth, and emotional and behavioral functioning. More research is required comparing integrated to non-integrated programs. This review highlights the need for improved methodology, study quality, and reporting to improve our understanding of how best to meet the needs of children of women with substance abuse issues.

Integrated programs for women with substance use issues and their children: a qualitative meta-synthesis of processes and outcomes

BackgroundThere is a need for services that effectively and comprehensively address the complex needs of women with substance use issues and their children. A growing body of literature supports the relevance of integrated treatment programs that offer a wide range of services in centralized settings. Quantitative studies suggest that these programs are associated with positive outcomes. A qualitative meta-synthesis was conducted to provide insight into the processes that contribute to recovery in integrated programs and womens perceptions of benefits for themselves and their children.MethodsA comprehensive search of published and unpublished literature to August 2009 was carried out for narrative reports of womens experiences and perceptions of integrated treatment programs. Eligibility for inclusion in the meta-synthesis was determined using defined criteria. Quality assessment was then conducted. Qualitative data and interpretations were extracted from studies of adequate quality, and were synthesized using a systematic and iterative process to create themes and overarching concepts.ResultsA total of 15 documents were included in the meta-synthesis. Women experienced a number of psychosocial processes during treatment that played a role in their recovery and contributed to favourable outcomes. These included: development of a sense of self; development of personal agency; giving and receiving of social support; engagement with program staff; self-disclosure of challenges, feelings, and past experiences; recognizing patterns of destructive behaviour; and goal setting. A final process, the motivating presence of children, sustained women in their recovery journeys. Perceived outcomes included benefits for maternal and child well-being, and enhanced parenting capacity.ConclusionA number of distinct but interconnected processes emerged as being important to womens addiction recovery. Women experienced individual growth and transformative learning that led to a higher quality of life and improved interactions with their children. The findings support the need for programs to adopt practices that focus on improving maternal health and social functioning in an environment characterized by empowerment, safety, and connections. Womens relationships with their children require particular attention as positive parenting practices and family relationships can alter predispositions toward substance use later in life, thereby impacting favourably on the cycle of addiction and dysfunctional parenting.

Maternal substance use and integrated treatment programs for women with substance abuse issues and their children: a meta-analysis

BackgroundThe rate of women with substance abuse issues is increasing. Women present with a unique constellation of risk factors and presenting needs, which may include specific needs in their role as mothers. Numerous integrated programs (those with substance use treatment and pregnancy, parenting, or child services) have been developed to specifically meet the needs of pregnant and parenting women with substance abuse issues. This synthesis and meta-analysis reviews research in this important and growing area of treatment.MethodsWe searched PsycINFO, MedLine, PubMed, Web of Science, EMBASE, Proquest Dissertations, Sociological Abstracts, and CINAHL and compiled a database of 21 studies (2 randomized trials, 9 quasi-experimental studies, 10 cohort studies) of integrated programs published between 1990 and 2007 with outcome data on maternal substance use. Data were summarized and where possible, meta-analyses were performed, using standardized mean differences (d) effect size estimates.ResultsIn the two studies comparing integrated programs to no treatment, effect sizes for urine toxicology and percent using substances significantly favored integrated programs and ranged from 0.18 to 1.41. Studies examining changes in maternal substance use from beginning to end of treatment were statistically significant and medium sized. More specifically, in the five studies measuring severity of drug and alcohol use, the average effect sizes were 0.64 and 0.40, respectively. In the four cohort studies of days of use, the average effect size was 0.52. Of studies comparing integrated to non-integrated programs, four studies assessed urine toxicology and two assessed self-reported abstinence. Overall effect sizes for each measure were not statistically significant (d = -0.09 and 0.22, respectively).ConclusionsFindings suggest that integrated programs are effective in reducing maternal substance use. However, integrated programs were not significantly more effective than non-integrated programs. Policy implications are discussed with specific attention to the need for funding of high quality randomized control trials and improved reporting practices.

Birth outcomes for infants born to women participating in integrated substance abuse treatment programs: A meta-analytic review

Background: Infants born to women with substance abuse issues are at increased risk for prematurity, low birth weight, and impaired physical development. Integrated programs (programs that integrate on-site pregnancy-, parenting-, or child-related services with substance use treatment) have been developed to address these risks, barriers to accessing care, and the unique needs of pregnant women who abuse substances. Method: To examine the effects of integrated programs on birth outcomes, we compiled a database of 10 studies (N = 2471) of integrated programs published between 1990 and 2009 with birth outcome data. Data were summarized and meta-analyses were performed. Results: Compared to women with substance abuse issues not in treatment, women in integrated programs had infants with significantly higher birth weights, larger head circumferences, fewer birth complications, positive toxicology screens, and low birth weight classifications (ds = 0.42–0.87). Women in integrated programs attended significantly more prenatal visits (d = 2.20) and had significantly fewer pre-term births (d = 0.35) than women in non-integrated programs. Conclusions: This is the first systematic quantitative review of studies evaluating the impact of integrated programs on birth outcomes. Findings suggest that integrated programs may be associated with advantages over non-integrated programs in increasing womens participation in prenatal care and decreasing premature delivery. This review highlights the need for further research with improved methodology, study quality, and reporting to improve our understanding of how best to meet the needs of pregnant women with substance abuse issues.

Maternal mental health and integrated programs for mothers with substance abuse issues.

To examine the impact of integrated treatment programs (those with substance use treatment and pregnancy-, parenting-, or child-related services) on maternal mental health, we compiled a database of studies of integrated programs published between 1990 and 2007 with outcome data on maternal mental health. There were 18 cohort studies, 3 randomized trials, and 2 quasi-experimental studies. Of the five studies comparing integrated to nonintegrated programs, three studies provided enough information to allow for them to be combined in a meta-analysis. The average effect size was 0.23 (95% CI = 0.15 to 0.31, SE = 0.04), p < .001. There was no statistically significant heterogeneity among the studies, Q = 5.66, p = .059. This meta-analysis is the first systematic quantitative review of studies evaluating the impact of integrated programs on maternal mental health. Findings suggest that integrated programs may be associated with a small advantage over nonintegrated programs in improving maternal mental health. This review highlights the need for further research with improved methodology, study quality, and reporting to improve our understanding of how best to meet the mental health needs of mothers with substance abuse issues.

“New Choices” for substance‐using mothers and their children: Preliminary evaluation

Setting, participants, intervention and measurement: New Choices is a centralized “one‐stop shop” in Hamilton, Ontario, Canada, that provides multiple services in a supportive environment for substance‐using women and their young children. Measures of substance use, social support, mental health, nutrition, parenting and child development were administered to 13 women (21–36 years old) and their 13 children (0–5 years old) when they entered the programme, and at 3 and 6 months thereafter. Findings: Results revealed a significant improvement in maternal empathy at 3 months and childrens social competence at 6 months, and a decrease in maternal support of childrens power and independence that was significant at 3 months but not at 6 months. Improvements in other outcomes were not statistically significant, but effect sizes were promising. Results showed more improvements after 6 than 3 months, suggesting that length of programme involvement may be an important factor in outcome. Conclusions: The findings from this small pilot study suggest that a “one‐stop” intervention for substance‐using mothers and their children might have a positive impact on many outcomes. This evaluation involved a small cohort sample, no comparison group and parent‐report measures only, so it should be viewed as exploratory and interpretation of findings made cautiously.

Evidence-informed decision-making by professionals working in addiction agencies serving women: a descriptive qualitative study

BackgroundEffective approaches to the prevention and treatment of substance abuse among mothers have been developed but not widely implemented. Implementation studies suggest that the adoption of evidence-based practices in the field of addictions remains low. There is a need, therefore, to better understand decision making processes in addiction agencies in order to develop more effective approaches to promote the translation of knowledge gained from addictions research into clinical practice.MethodsA descriptive qualitative study was conducted to explore: 1) the types and sources of evidence used to inform practice-related decisions within Canadian addiction agencies serving women; 2) how decision makers at different levels report using research evidence; and 3) factors that influence evidence-informed decision making. A purposeful sample of 26 decision-makers providing addiction treatment services to women completed in-depth qualitative interviews. Interview data were coded and analyzed using directed and summative content analysis strategies as well as constant comparison techniques.ResultsAcross all groups, individuals reported locating and using multiple types of evidence to inform decisions. Some decision-makers rely on their experiential knowledge of addiction and recovery in decision-making. Research evidence is often used directly in decision-making at program management and senior administrative levels. Information for decision-making is accessed from a range of sources, including web-based resources and experts in the field. Individual and organizational facilitators and barriers to using research evidence in decision making were identified.ConclusionsThere is support at administrative levels for integrating EIDM in addiction agencies. Knowledge transfer and exchange strategies should be focussed towards program managers and administrators and include capacity building for locating, appraising and using research evidence, knowledge brokering, and for partnering with universities. Resources are required to maintain web-based databases of searchable evidence to facilitate access to research evidence. A need exists to address the perception that there is a paucity of research evidence available to inform program decisions. Finally, there is a need to consider how experiential knowledge influences decision-making and what guidance research evidence has to offer regarding the implementation of different treatment approaches within the field of addictions.

Using a knowledge transfer framework to identify factors facilitating implementation of family‐based treatment

OBJECTIVE To conduct a qualitative study to identify factors that would facilitate the transfer of the research evidence on Family-Based Treatment (FBT) into clinical practice. METHOD Fundamental qualitative description guided sampling, data collection, and analytic decisions for this study. Forty therapists who treat children and adolescents under the age of 18 with Anorexia Nervosa (AN) and belong to Ontarios provincial network of specialized eating disorder services completed an in-depth interview focusing on elements proposed by the Lavis knowledge transfer framework. An experienced coder conducted content analysis, with 20% of the interviews double-coded for reliability purposes. RESULTS Participants requested training in the FBT model, including the provision of research evidence (i.e., journal articles), as well as the specific tenets of the model according to the FBT manual. The suggested audience for implementation included not only therapists themselves, but administrators, physicians, and community members. The development of best practice guidelines was also supported. Local FBT experts were suggested as credible messengers. Infrastructure relating to financial support and time away from clinical duties were reported to be essential for training. Ongoing supervision and mentorship were reported to be important elements of implementation and evaluation processes. DISCUSSION Suggestions for moving FBT into practice were consistent with previous research, however, the importance of obtaining the evidence in the form of primary research articles and obtaining team buy-in were remarkable. Developing context-specific training programs and administrative processes for the implementation of FBT are warranted.