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Regular article
Rethinking parenting interventions for drug-dependent mothers:
From behavior management to fostering emotional bonds
Nancy Suchman, (Ph.D.)
a,
*, Linda Mayes, (M.D.)
b
, Joanne Conti, (M.A.)
c
,
Arietta Slade, (Ph.D.)
b
, Bruce Rounsaville, (M.D.)
a
a
Yale University School of Medicine, Department of Psychiatry, New Haven, CT, USA
b
Yale Child Study Center, New Haven, CT, USA
c
University of Hartford, Graduate Institute of Professional Psychology, Hartford, CT, USA
Received 26 March 2004; received in revised form 15 April 2004; accepted 15 June 2004
Abstract
Mothers who are physically and/or psychologically dependent upon alcohol and illicit drugs are at risk for a wide range of parenting
deficits beginning when their children are infants and continuing as their children move through school-age and adolescent years.
Behavioral parent training programs for drug-dependent mothers have had limited success in improving parent-child relationships or
childrenTs psychological adjustment. One reason behavioral parenting programs may have had limited success is the lack of attention to
the emotional quality of the parent-child relationship. Research on attachment suggests that the emotional quality of mother-child
relationships is an important predictor of childrenTs psychological development through school-age and adolescent years. In this paper, we
present a rationale and approach for developing attachment-based parenting interventions for drug-dependent mothers and report
preliminary data on the feasibility of offering an attachment-based parenting intervention in an outpatient drug treatment program for
women. D2004 Elsevier Inc. All rights reserved.
Keywords: Parenting skills; Parent training; Maternal addiction; Mother-child relations; Child maltreatment
1. Introduction
Mothers who are physically and/or psychologically
dependent upon alcohol and illicit drugs (i.e., heroin,
cocaine, marijuana) are at risk for a wide range of parenting
deficits beginning when their children are infants and
continuing as their children move through school-age and
adolescent years (for a review, see Mayes & Truman, 2002).
As a group, drug-dependent mothers fare worse than non
drug-dependent mothers on a wide range of parenting
indices and more frequently lose their children to foster care
than non drug-dependent mothers (Chaffin, Kelleher, and
Hollenberg, 1996; Mayes & Bornstein, 1996). Observations
of mother-infant dyads have shown patterns of mothersT
poor sensitivity and responsiveness to childrenTs emotional
cues juxtaposed with heightened physical activity, provo-
cation, and intrusiveness (Burns, Chethik, Burns, & Clark,
1997; Hans, Bernstein, & Henson, 1999; Rodning, Beck-
with, & Howard, 1991). Studies reporting perspectives of
substance-abusing mothers about parenting have indicated a
lack of understanding about basic child development issues,
ambivalent feelings about having and keeping children, and
lower capacities to reflect upon their childrenTs emotional
and cognitive experience (Levy, Truman, & Mayes, 2001;
Mayes & Truman, 2002; Murphy & Rosenbaum, 1999).
Self-reported behaviors among drug-dependent mothers
have also revealed harsh, threatening, overly-involved,
authoritarian parenting styles juxtaposed with permissive-
ness, neglect, poor involvement, low tolerance of child
demands and misbehavior, and parent-child role reversals
0740-5472/04/$ – see front matter D2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2004.06.008
* Corresponding author. Yale Psychosocial Substance Abuse Research
Center, VA-CT Healthcare Center (151D), 950 Campbell Ave., West
Haven, CT 06516. Tel.: +1-203-937-3486; fax: +1-203-937-3472.
E-mail address: nancy.suchman@yale.edu (N. Suchman).
Journal of Substance Abuse Treatment 27 (2004) 179 – 185
(Harmer, Sanderson, & Mertin, 1999; Mayes & Truman,
2002; Suchman & Luthar, 2000).
1.1. Previous clinical trials involving parent skills training
Several parenting skills training studies involving drug-
dependent parents have been reported to date, including
two randomized clinical trials. Generally, the objectives of
these parent training programs have been to reduce mal-
adaptive parenting practices (e.g., harsh punishment),
improve positive parenting skills (e.g., behavior management
through rewards and punishment) and thereby reduce
problematic child behaviors (e.g., externalizing and drug
abuse). Although some of these programs (see Ashery,
Robertson, & Kumpfer, 1998) have demonstrated success
at changing parenting practices and reducing childrenTs
conflict-producing behaviors, generally, parent skills training
programs have not led to lasting improvement in the quality
of the parent-child relationship or fostered improvement in
childrenTs psychological functioning. For example, in a
randomized clinical trial, Catalano, Gainey, Fleming, Hag-
gerty, and Johnson (1999) tested the efficacy of a parent
training program combining 16 weeks of parent skills
training and 9 months of home-based case management for
144 methadone maintained parents of children ages 4–16.
The program provided training in relapse prevention, anger
management, and parenting skills. At the 12-month followup,
parents who received parent training showed greater ability in
abstinence from heroin use, drug-use related problem-
solving, maintenance of household rules, and domestic
conflict. However, they showed no advantage over the
control group on indices of family bonding, family conflict,
or childrenTs reports of parental involvement. Moreover, at
followup, of 11 child adjustment indices measured (e.g.,
behavior problems, negative peer networks), the only statisti-
cally significant group difference (childrenTs prosocial
involvement with parents) favored the control group. In
another randomized clinical trial, Kumpfer (1998) examined
the efficacy of the Strengthening Families Program (SFP), a
14-week drug abuse prevention program targeting children
ages 6–10 reared in families with drug-dependent parents.
The authors used an experimental dismantling design to test
the efficacy of parent skills training alone vs. the addition of
social skills training for children and behavioral family
therapy. The parent training component of SFP was designed
to decrease parentsTdrug use, improve positive parenting
skills (e.g., discipline, rewards, and punishment), and reduce
physical punishment. In a NIDA Monograph report, Kumpfer
(1998) reported that the parenting program improved the
parentsTability to reduce negative, acting-out behaviors in
children and improve child compliance with parental
requests. However, the parent training program alone did
not improve childrenTs pro-social skills (i.e., communication,
problem solving, peer resistance, and goal setting). More-
over, the authors reported that family relationships actually
deteriorated when the parent training program was imple-
mented alone. Children reported at posttest that they did not
believe their parents loved them as much as before the
parenting program started. It is possible that, without
strengthening emotional bonds between parents and children,
children experience more stringent behavior management as
punitive and uncaring.
Taken together, findings from these well-designed
clinical trials of parent training programs indicate that,
whereas they may have some short-term efficacy for
increasing parentsTbehavior management strategies aimed
at reducing childrenTs conflict-producing behaviors, they do
not lead to long-term improvement in the quality of parent-
child relationships or childrenTs psychological adjustment.
1.2. Why parent training programs may not work
One reason parent skills training programs may fail to
bring about generalized changes in parent-child relationships
and childrenTs psychological development is their exclusive
focus on procedures of overt behavior management skills
(e.g., rewards, punishment, discipline), and relatively little
attention to helping parents understand the emotional needs
driving their childrenTs behavior. In parent skills training,
parents learn to apply behavior management techniques that
immediately reduce childrenTs conflict-producing behavior.
Less attention is given to the emotional needs underlying
childrenTs problematic behaviors, such as needs to experi-
ence physical safety, emotional reassurance, and acceptance/
encouragement of autonomy, that occur within the context of
the parent-child relationship (Speltz, 1990).
Parent training programs also pay less attention to
fostering parentsTemotional availability and responsiveness
to children, or the capacity to respond to childrenTs
emotional cues in an emotionally open and flexible manner.
It has been well documented that parents who are at high
risk for maladaptive patterns of relating to their children
(e.g., drug-dependent parents) often have their own long-
standing relational difficulties that make it difficult to
respond to children in an emotionally available way (e.g.,
with empathy, warmth, and acceptance toward the childTs
emotional needs). The failure of parent training programs to
bring about changes in relationship quality and childrenTs
psychological well-being may be due not only to their lack
of attention to childrenTs emotional needs, but also to their
lack to attention to more deeply engrained limitations in
parentsTemotional experiences and responses in the parent-
ing role (Egeland, Weinfield, Bosquet, & Cheng, 2000; van
IJzendoorn, Juffer, & Duyvesteyn, 1995).
1.3. An attachment-based perspective on parenting
interventions for drug-dependent mothers
1.3.1. The importance of the emotional quality of the
mother-child relationship
Originating with the ideas of John Bowlby (1982),
attachment research over the past 30 years has shown that
N. Suchman et al. / Journal of Substance Abuse Treatment 27 (2004) 179–185180
emotional aspects of the parent-child relationship (i. e., the
capacity of a parent to recognize childrenTs emotional needs
and respond to them in an emotionally available way) are
important predictors of childrenTs psychological develop-
ment. In general, attachment research has shown that, when
parents are able to accurately perceive and sensitively
respondtotheirchildrenTs emotional needs (e.g., for
comfort, security, autonomy) during infancy and toddler
years, children are more likely to be psychologically well
adjusted (e.g., socially competent with absence of behavior
problems) in their school-aged and adolescent years (see
Egeland, Weinfeld, Bosquet, & Cheng, 2000; Sroufe,
Carlson, Levy, & Egeland, 1999 for a review of longitudinal
studies on attachment). Likewise, when parents misperceive
or respond insensitively to childrenTs emotional cues during
infancy and toddler years, children are more likely to show
signs of emotional disturbance, problems in social com-
petence, and behavior problems during their school-aged
and adolescent years. Even when childrenTs individual
temperament has been taken into account in attachment
studies, maternal sensitivity to childrenTs emotional cues
and emotional availability appear to be protective factors for
childrenTs psychological development.
1.3.2. Mechanisms by which mothers develop the capacities
for maternal sensitivity and emotional availability in the
mother-child relationship
1.3.2.1. Internal working models of the care-giving relation-
ship. According to attachment theory, in the early care-
giving relationship, when primary caregivers accurately
perceive and sensitively respond to childrenTs emotional
needs in a consistent manner over multiple instances, their
children have the repeated experience of the caregiver as
emotionally sensitive, available, and responsive during
episodes of emotional distress and of being effectively
soothed by the caregiverTs efforts. According to attachment
theory, over time, children develop an internal mental
representation of the care-giving relationship (what Bowlby
referred to as an binternal working modelQ) based on the
multiple interactions that transpired with the caregiver
during instances of emotional distress. Children whose
early caregivers were able to recognize their signals of
emotional distress, and respond in an emotionally sensitive
and flexible manner are thought to develop mental
representations of the care-giving relationship that are
emotionally balanced (i.e., include both positive and
negative emotions), realistic and coherent (i.e., memories
of specific instances that help characterize the relationship
are imminently accessible), and non-defensive (i.e., no
distortion or denial of painful emotional aspects of the
relationship). Children whose early care givers misperceived
their signals of distress or responded in rigid, controlling,
chaotic, or frightening ways to childrenTs emotional distress,
are thought to develop mental representations of the care-
giving relationship that are emotionally imbalanced (i.e.,
excessively positive, negative, or neutral), unrealistic and
incoherent (i.e., memories of specific instances that help
characterize the relationship are either inaccessible or
distorted), and defensive (i.e., painful emotional aspects
are either denied or distorted).
1.3.2.2. Internal working models as prototypes for care-
giving relationships in the next generation. Internal
working models are thought to serve as prototypes for all
subsequent relationships in adulthood including the next
generation of care-giving relationships (Sroufe et al., 1999).
Attachment researchers have generally found that mothers
who reported feeling secure in their relationships with their
own parents have more flexible relational styles as parents
that allow them to perceive their childrenTs emotional cues
and be emotionally available and responsive to their
childrenTs emotional needs. Likewise, their children are
more likely to express feelings and needs directly and
openly without fearing a loss of security (Slade & Cohen,
1996). These mothers are thought to have mental represen-
tations of the care-giving relationship that are accessible,
coherent, balanced in terms of positive and negative affect,
and realistic (e.g., undistorted). This balanced representation
of the care-giving relationship is thought to allow mothers to
perceive childrenTs emotional cues (without defensive
denial or distortion) and respond to childrenTs emotional
cues in emotionally available and flexible ways. Mothers
who did not feel secure in relationships with their own
parents are thought to have internalized mental representa-
tions of the care-giving relationship that are characterized by
exclusion or distortion of painful affect that causes them to
either deny or be overwhelmed by (and distort) their
childrenTs emotional needs (Solomon & George, 1996).
1.3.2.3. Reflective functioning: the metacognitive capacity
to monitor thoughts and emotions and their influence on
behavior. In order for a mother to become more sensitized
to her childTs emotional cues, she must also have the
capacity to monitor her childTs cognitive and affective
experiences and be able to recognize that these experiences
influence behavior. For example, in order for a mother to
understand that her 2-year-old sonTs crying upon her
departure is a cue that he is struggling with emotions about
separation, she must have the capacity to recognize her
childTs mental experience (e.g., fear) and also have the
capacity to recognize that the childTs mental experience
(e.g., fear) is influencing the childTs behavior (e.g., crying).
Recognition of a childTs mental states and their influence on
behavior also involves recognition of oneTs own mental
states and their influence on behavior; otherwise, distinction
between the mothersTand childrenTs mental experiences is
not possible. During the past 5 years, Fonagy and colleagues
(Fonagy et al., 1995; Fonagy, Gergely, Jurist, & Target,
2002; Fonagy & Target, 1997) have been examining this
metacognitive capacity for breflective functioningQand have
found in both low- and high-risk samples of mothers that
N. Suchman et al. / Journal of Substance Abuse Treatment 27 (2004) 179–185 181
maternal capacity for breflective functioningQis associated
with maternal ways of thinking about the care-giving
relationship, with maternal behaviors in mother-child
interactions (e.g., flexibility and sensitivity), and with
childrenTs felt security (Grienenberger, Kelly, & Slade,
2001; Slade, Grienenberger, Bernbach, Levy, & Locker,
2001). Importantly, low levels of reflective functioning
have been associated with insensitive and emotionally
unresponsive maternal behaviors (e.g., withdrawal, hostility,
intrusiveness, and distorted perceptions of affective com-
munication). Maternal capacity for reflective functioning
has also been found to mediate associations between
maternal substance abuse and childrenTs psychosocial
development (e.g., attention, social skills, and withdrawal;
Levy and Truman, 2002). Thus, the maternal capacity to
monitor her own and her childTs mental states is another
important component for developing maternal sensitivity to
childrenTs emotional cues.
1.4. Can intervention foster improvement in maternal
sensitivity and emotional availability in at-risk mothers?
1.4.1. Maternal sensitivity
A number of researchers have evaluated the preliminary
efficacy of attachment-based parenting interventions with
high-risk mothers (for reviews see Bakermans-Kranenburg,
van IJzendoorn, & Juffer, 2003; Egeland et al., 2000; van
IJzendoorn et al., 1995). These studies have shown that
maternal sensitivity (mothersTability to accurately perceive
childrenTs emotional cues and understand them within a
developmental context) can be improved through short-term
intervention. Specifically, providing developmental guid-
ance to mothers about their childrenTs emotional needs and
their behavioral manifestations at different ages has helped
at-risk mothers become more accurate and sensitive
perceivers of their childrenTs emotional cues. However,
improvements in maternal sensitivity alone have not
corresponded with improvement in the emotional quality
of the mother-child relationship. Particularly in the case of
at-risk mothers, other maternal factors, including emotional
availability and concomitant psychosocial problems, are
thought to play important roles in the quality of the mother-
child relationship and childrenTs psychological development.
1.4.2. Maternal emotional availability
Attachment-based clinicians have generally thought that,
for a mother to become more emotionally available and
responsive to her child, her thoughts and feelings (i.e.,
mental representations) about her relationship with her child
must first change. Although mental representations of the
motherTs early care-giving relationship are ordinarily diffi-
cult to access, within the context of current, newly formed
relationships with children, the motherTs forming mental
representation of her relationship with her own child is
thought to be more accessible and amenable to change
(Slade & Cohen, 1996). Change in the motherTs mental
representations of her relationship with her child are thought
to occur through (a) a secure relationship with a caring
clinician that allows her to (b) explore previously denied or
distorted affect about the care-giving relationship and its
impact on her own parenting behavior and her childTs
emotional experience (Pawl & Lieberman, 1997). Studies of
short-term attachment-based parenting interventions with
high-risk mothers have shown that mothersTmental repre-
sentations of care-giving can change in response to
intervention (Cramer et al., 1990; Robert-Tissot et al., 1996).
1.4.3. Concomitant psychosocial disturbance
There is a growing consensus among parent skills
training and attachment-based parenting intervention
researchers alike that drug-dependent mothers are at risk
for multiple psychosocial deficits that call for comprehen-
sive services to be offered in conjunction with parenting
interventions. In their review of attachment-based parenting
interventions for high-risk mothers, Egeland and colleagues
(2000) note that narrowly-focused attachment-based parent-
ing interventions are not potent enough to address the
myriad other problems mothers face, including co-morbid
psychopathology and problems of daily living exacerbated
by poverty. They suggest that attachment-based parenting
interventions for high-risk mothers are more likely to
improve parenting relationships and childrenTs adjustments
when they are offered within a comprehensive treatment
setting that includes treatment for other psychosocial
problems such as drug addiction, psychiatric illness (e.g.,
depression, anxiety), and problems of daily living (e.g.,
housing, shelter, food, child care, and so forth).
1.5. Implications for therapeutic intervention model
Together, the mechanisms outlined above point to the
need for therapeutic parenting interventions that aim to
foster maternal sensitivity and emotional responsiveness to
childrenTs emotional needs and capacities at different ages
within a clinical setting where comprehensive services are
available, including treatment for drug dependence, psychi-
atric illness, and problems of everyday living.
1.5.1. Maternal sensitivity
In order to foster improvement in maternal sensitivity, or
the motherTs capacity to recognize her childrenTs emotional
needs (e.g., safety, security, autonomy) and their behavioral
manifestations (e.g., crying, clinging, fighting, defiance),
parenting interventions will need to focus on expanding
mothersTknowledge of childrenTs emotional needs and
abilities at different ages as well as their capacity to make
reasonable inferences about the emotional states underlying
their childrenTs behavior. Therapeutic strategies related to
this objective include providing timely developmental
guidance about childrenTs emotional needs and psychosocial
capacities at different ages and how they are behaviorally
expressed, and providing opportunities to observe and
N. Suchman et al. / Journal of Substance Abuse Treatment 27 (2004) 179–185182
explore mother-child interactions with mothers to assist in
the development of their capacities to make accurate
inferences about the thoughts and feelings underlying their
childrenTs behavior. Timely developmental guidance
involves imparting developmental information about chil-
drenTs emotional needs and psychosocial capacities and
about relational dynamics in the care-giving relationship. It
also involves imparting knowledge about how these capaci-
ties and dynamics will evolve over time. For instance,
providing mothers of toddlers with basic information about
their limited capacities to remember instructions, visualize
the caregiver in her absence, or regulate impulses and
affective distress can support changes in the motherTs
sensitivity to the childTs needs and abilities. Providing basic
information to mothers about their toddlersTneeds for them
(the mothers) to serve as a secure emotional base from which
the child can feel safe to explore can also help mothers
interact more sensitively when their children express needs
for proximity and autonomy (rather than experiencing these
bids as intrusions or rejections). The timing of such
interventions is critical, such that the mother must perceive
the information as relevant and useful rather than as
unwelcome advice or criticism.
1.5.2. Emotional availability
Attachment theory suggests that emotional availability,
the motherTs capacity to tolerate her childTs emotional needs
and respond to them in a flexible and emotionally open
manner, is driven by her internal working model of the care-
giving relationship. It follows then, that improvement in
maternal emotional availability is not possible without
change in the motherTs internal representations of the care-
giving relationship. Therapeutically, changes in maternal
representations of the child and the care-giving relationship
are thought to occur within the context of a secure
relationship with a caring adult (e.g., a therapist) in which
previously distorted or denied thoughts and feelings about
the child and care-giving relationship can be recognized and
resolved (i.e., attributed to their original sources).
Therapeutic strategies related to this objective include
fostering a therapeutic alliance and exploring maternal
cognitions and affect in the parenting relationship. In order
for a mother to talk openly about these negative experiences
as a parent, she needs to experience the therapist as being
bwith her,Qinterested in and accepting of aberrant views and
affective reactions to parenting (Fraiberg, Adelson, &
Shapiro, 1987; Pawl & Lieberman, 1997). The therapeutic
alliance can be fostered by providing a balance of genuine
interest and concern, acceptance of wide-ranging concerns
and beliefs about parenting, empathy for emotional distress,
clear and direct communication about the limitations of the
therapeutic relationship (e.g., avoiding false promises about
therapist availability or custody outcomes), and taking direct
action to protect children in harmTs way.
Previously distorted or denied affect toward the child in
the care-giving relationship can be identified and redirected
to original sources by exploring mothersTaffective distress
in the parenting role and the sources of her emotional
distress other than her child. Preoccupations with inter-
personal loss and trauma, feelings of shame, defiance, and
neediness are readily and repeatedly activated by childrenTs
everyday emotional demands (Solomon & George, 1996)
and thus become accessible to the mother and therapist who
can then work together to identify original sources and
replace distorted representations of children with more
balanced and accurate dworking modelsTof the child and
the care-giving relationship.
1.5.3. The clinical setting
The drug treatment clinic where drug-dependent mothers
are often referred by child welfare for treatment for
problems with drug abuse and psychiatric disturbance is,
in many ways, an ideal setting for providing therapeutic
parenting interventions for mothers who are overwhelmed in
their roles as parents. The drug treatment clinic provides a
structured program for focusing on abstinence and relapse
prevention, ready access to medical and psychiatric care and
individual assistance with problems of daily living, and a
potential social network of peers focusing on the common
issues of parenting and recovery. The addition of a
therapeutic parenting intervention to an intact, comprehen-
sive treatment delivery program can permit a coordinated
effort to simultaneously address parenting deficits and other
acute psychosocial problems.
1.5.4. Intervention format
The theoretical framework and therapeutic objectives
outlined above are most likely to be effectively addressed in
an individual therapy format that maximizes a strong,
positive therapeutic alliance and flexibility in tailoring the
intervention to the specific needs of the mother-child dyad.
There are reasons to suggest that targeting parenting
interventions to mothers of toddlers (e.g., ages 18 to
36 months) would yield the greatest benefit: First, from an
attachment perspective, a motherTs capacity to foster chil-
drenTs sense of security and autonomy during this period
through sensitive, emotionally open interactions is critical to
childrenTs subsequent psychosocial development (e.g.,
social competence, adaptive behavior, success in school).
Second, in our clinical work with drug-dependent mothers
we have observed that childrenTs natural autonomous forays
and expressions of defiance beginning at 18 months often
mark the onset of acute distress in the mother-child dyad,
strong negative affect toward the child, and harsh, punitive
parenting practices, and that this acute distress is charac-
terized by mothersTconfusion and distortion about chil-
drenTs intentions, abilities, and needs at this stage of
development. Third, mothersTrepresentations of the rela-
tionship with toddlers/preschoolers vs. school-aged/adoles-
cent children are relatively new and more amenable to
change. Fourth, during school-age and adolescent years, a
motherTs influence in child development is diffused by the
N. Suchman et al. / Journal of Substance Abuse Treatment 27 (2004) 179–185 183
increased influence of peers and other adults. Fifth, focusing
on a broader age span compromises the depth of the
interventionTs developmental sensitivity and specificity to
any particular age.
2. Materials and methods
2.1. Feasibility data from a pre-pilot study
The authors recently piloted a parenting intervention
based on the rationale and approach outlined above with
25 mothers referred by child welfare for treatment to an
outpatient drug treatment program for women in New Haven,
CT. In this pre-pilot study, we compared 25 mothers enrolled
in the adjunct parenting intervention with 23 mothers who
received standard treatment alone on indices of treatment
attendance, retention, compliance, and drug use at discharge.
The adjunct parenting intervention took place for 1.5 h per
week for 12 weeks in addition to standard treatment and was
conducted by the principal author, N.S., and two M.S.W.
therapists who were trained by the authors. Standard treat-
ment for women at the clinic involved one of two tracks: a
12-week outpatient treatment program where women
attended two groups per week (e.g., a supportive group
therapy intervention and a group relapse prevention inter-
vention) or a 12-week an intensive outpatient program that
women attend 3 days per week for 3 hours of group therapy
each day (groups focused on womenTs issues, trauma, relapse
prevention, and time management).
Using chart reviews, we compared the 25 mothers
who enrolled in the parenting intervention with 23 mothers
who received standard treatment at the clinic during the same
year on indices of treatment attendance, compliance,
retention, completion, and abstinence from drug use at the
time they were discharged from the program. Intervention
mothers attended an average of eight sessions and were
retained an average of 10 weeks, compared with an average
of six sessions and 8 weeks retention in the standard
treatment group. Both these differences were marginally
significant ( pb.06) but had moderate effect sizes of .52
and .54, respectively. Mothers in the parenting intervention
were also more compliant in following clinical advice
than mothers enrolled in standard treatment alone (v
2
=
12.13, p= .001). Group differences in treatment completion
(v
2
= 2.45, p= .145) were not significant, although a small
effect size (d= .22) favored mothers who received the
parenting intervention. Group differences in abstinence
from drug and alcohol use at discharge were not significant
(v
2
= .25, p= .748).
3. Discussion
Over the past decade, although several randomized
clinical trials testing behavioral parenting interventions have
shown some improvement in parentsTimplementation of
behavioral management strategies and reduction in chil-
drenTs conflict-produc ing behaviors, intervention efforts have
shown little success in improving the emotional quality of
parent-child relationships or fostering childrenTs psychoso-
cial development. To interrupt pervasive patterns of physical
and emotional neglect across generations in families
affected by maternal drug-dependence, it may be necessary
for parenting interventions to take into account the emo-
tional quality of the parent-child relationship as well as the
behavior management skills of parents. Attachment theory
and research offers much in the way of a clear conceptual
model and a multifaceted intervention approach that may
hold greater promise for strengthening emotional bonds,
maximizing childrenTs chances for optimal psychosocial
development, and interrupting the transmission of mal-
adaptive parenting practices across generations. In this
report we presented the rationale, therapeutic objectives,
and preliminary feasibility data for an attachment-based
parenting intervention for drug-dependent mothers that aims
to improve maternal sensitivity and emotional availability in
the care-giving relationship.
Acknowledgments
The authors wish to thank Michelle Altomare and
Felicity Moller for their able assistance in data collection
and management. We are grateful to Nicole Apicella,
Rebecca Kramer-Koenigsberg, Elaine Fagan, Jean Larson,
and patients at the APT Foundation for their support and
participation in this project. This project was funded by
NIDA Grant #K23-DA14606 and the APT Foundation, Inc.
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