The potential impact and treatment implications of co-morbid impulse control disorders. Sharon Dawe, Denise Hatzis, Paul Harnett and Jane Barlow.

1. Quality of caregiving in substance abusingQuality of caregiving in substance abusing
mothers: The potential impact andmothers: The potential impact and
treatment implications of co morbidtreatment implications of co morbid
impulse control disordersimpulse control disorders
Sharon Dawe, Denise Hatzis, Paul Harnett &
Jane Barlow
s.dawe@griffith.edu.au

2. What we know
Substance abuse is associated with:
Increased risk for child maltreatment and neglect
Poorer child outcomes, early school failure, use of
substances poor social skills, affect dysregulation.
Greater involvement of child protection agencies
and children being removed from parental custody
High rates of comorbid MATERNAL psychopathology
Caregiving in substance
abusing mothers

3. BUT WHAT DOES THIS MEAN ON ABUT WHAT DOES THIS MEAN ON A
CASE BY CASE BASIS?CASE BY CASE BASIS?
Caregiving in substanceCaregiving in substance
abusing mothersabusing mothers

4. Intergenerational transmission
of insecure attachment
Childhood and adult
trauma of mother
Presence of co morbid
psychopathology
Reduced perception of
available social support
especially spousal support
Compromised caregiving is
influenced by multiple factors

5. Five Attachment Studies Identified:
Swanson et al. (2000) Part of Longitudinal study :51
S/A dyads
Explore intrusive caregiving and quality of
attachment at 1, 6 & 18 mths
KEY FINDING:@ 18 mths - toddlers – 19% Secure,
14% Avoidant, 4% Resistant & 45% disorganised
Espinosa et al. (2001) : 35 cocaine–using mothers
18 mths toddlers – 31% secure, 14% avoidant, 6%
resistant, & 49% of toddlers disorganised
↓ sensitive caregiving at 1 & 6 mths assoc. sig with
toddlers with disorganised attachment
Reviewing the data on
attachment classification in
substance abusing mothers

6. Beeghly et al. (2003): 29 heavy cocaine exposed,
61 light cocaine exposed, 64 no cocaine exposure.
KEY FINDING:12 mths toddlers overall – 59%
secure, 10% avoidant, 6% resistance, & 21%
disorganised.
Seifer et al. (2004) Prospective study 860 dyads at
18 mths 732 at 36 mths
KEY FINDING: 18 & 36 mths
Secure > 65-69%;Disorganise < 12% - 6 %,
Ambivalent > 8 %- 14%;Avoidant< 11% -9%.
Cocaine + opiate mothers secure children↓
Reviewing the data on
attachment classification in
substance abusing mothers

7. What does this tell us?
Highlights the variability in studies
Raises questions about the quality of caregiving –
suggesting that in many cases it is certainly “good
enough”
But can we glean anything from the literature on
what may determine when the caregiving will be
“good enough”?

8. Systematic review: reviews all published
and “gray” literature by developing a set of
search terms,
Meta analysis: studies meeting these search
terms are then further analyses. Data is
extracted from each study and combined
into a single analysis.
Undertaking a systematic
review & meta analysis

9. SEARCH TERMS:Key words were entered for the
following title and abstract search: (maternal
substance use OR maternal drug use OR substance
using mothers OR drug using mothers) AND
(caregiving OR care giving OR interaction). All data
bases including OVID, PSYCH INFO Medline.
(PRISMA Guidelines followed)
Undertaking a systematic review
& meta analysis

10. INCLUSION CRITERIA:
(i)quantitative study;
(ii)antenatal maternal substance use;
(iii)infants were less than three years of age when
maternal-infant interactions were assessed;
(iv) maternal-infant interactions were assessed
using an observational method, videotaped and
coded to assess the quality of caregiving
(v)studies needed to include a comparison group of
non-substance using mothers.
Undertaking a systematic
review & meta analysis

11. EXTRACTED DATA ON
Maternal sensitivity: maternal response to infant
or child cues related to maternal warmth in
situations of low frustration rather than during
situations of frustration or negative affect
Child responsivity: explicitly measure
involvement or responsiveness of the infant such as
“involvement with the mother, positive feelings
shown to mother
Independently coded (SD & JB)
Undertaking a systematic
review & meta analysis

12. Studies included in the meta-analysis (n = 20)
Total Publication identified for screening (n = 2120)
Articles excluded on the basis of preliminary
review of titles and abstract:
• Duplicates (n = 153)
• Not pertaining to review
specifications (n = 1702)
Publications chosen for investigative review
process (n = 277)
Articles excluded after investigative review:
• Books (n = 11)
• Children’s age > 3 years (n = 13)
• Included data from foster carers (n = 1)
• Data from high risk populations not including substance
abuse (n = 10)
• Data from a single case design (n = 1)
• Data from unpublished manuscripts (n = 12)
• No observational measure of caregiving (n = 89)
• Theoretical articles / review articles or meta-analytical
data (n = 56)
• Articles published prior to 2000 after discovery of prior
review in the 2000 (n = 21)
• Published in more than one journal (n = 14)
• Did not include a matched comparison group of non
substance using mothers (n=22)
Articles meeting the inclusion criteria (n = 27)
Articles included from other sources (n = 12)
Articles removed as same data reported from
longitudinal cohort studies (n = 7)

13. Standardised effect sizes (d) were calculated for
the included studies using a random-effects model
A forest plot was calculated in Review Manager 5
(Version: 5.3.5) and the heterogeneity between
studies was assessed using the Q statistic and I2
index.
Sub-group analyses were carried out to investigate
sources of heterogeneity.
Sensitivity analyses using a priori weight functions
were carried out to determine whether the
estimates of effect size were likely to be influenced
by publication bias.
Undertaking a systematic
review & meta analysis

16. Substance use matters – but note the effect sizes
are small and only just significant
In treatment/out of treatment no difference
Methadone/or other substitution therapy no
difference
Poverty matters – financial disadvantage, receipt of
MediAid, low SES, - a lot
What appear to be the
factors implicated in
caregiving quality?

17. Co morbid psychopathology could not be tested in
the meta analysis
However, narrative analysis of the few studies that
have investigated this suggest this matters – a lot.
Maternal psychopathology (9 studies)
Depression – 4 studies
Paranoia, narcissism, features of borderline – 3
studies
Personality features and Maternal aggression – 2
studies
What appear to be the
factors implicated in
caregiving quality?

18. In all of these studies co morbid psychopathology
was significantly associated with the quality of care.
However, it is difficult to tease apart the relative
contribution of this and substance abuse.
My interpretation of this data:
1.Substance use does not preclude good quality
caregiving, methadone is irrelevant
2.Poverty plays a large role
3.Which co occurs with psychopathology – but I
think when considering the literature from BPD this
matters probably more so than substance abuse
What appear to be the
factors implicated in
caregiving quality?