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Implementing a Mindfulness-Based Intervention for Child Welfare-

Involved Families with Substance Misuse October 11-13, 2015

Haruv Institute 3rd International Mentoring Workshop

Samantha M. Brown, MA, LPC, PhD Candidate

University of Denver Graduate School of Social Work

Objectives

Introduce a mindfulness-based intervention model that integrates stress management, substance use treatment, and parenting to improve domains

of family functioning

Present preliminary findings from dissertation research

Seek consultation on the research design and implementation of this study on child maltreatment

Children with parents who misuse substances are more likely to experience maltreatment than children in other households (Dube et al., 2001; Hanson et al., 2006)

In the United States, an estimated 70% of child welfare cases involve parental substance use (CASA, 2005)

Child Maltreatment & Parental Substance Misuse

Consequences of Co-Occurring Substance Use and Maltreatment

Substance Use &

Maltreatment

Out-of-home care, termination

of parental rights, re-reports

to CPS

Dysfunctional Family

Interactions

Poor Child Health,

Development, and Behavioral

Problems

(Haris-McKoy et al., 2013; Osborne & Berger, 2009)

Role of Stress & Coping in Child Maltreatment and Substance Use

Child Maltreatment & Substance

Use

Stress-Related

Impairments in Executive

Function

Exposure to stress

Maladaptive Coping

(Kahng et al., 2008; Sinha, 2007; Wells, 2009)

Families report elevated rates of both acute and chronic stress (Estefan et al., 2013)

“Cookie-Cutter” approach to treatment Mandated treatment plans

Pressure to secure safe and permanent homes for children in limited timeframe Few assessments documenting myriad risk factors underlying the initial report of

abuse and neglect

Context of Child Welfare

Trauma-focused cognitive behavioral therapy

Behavioral parent training

Relational parenting

Home-visiting programs

Parent psychoeducation

Current Interventions in Child Welfare

Substance use and parenting programs implemented in isolation (Marsh et al., 2011)

Programs have not been systematically evaluated or have

demonstrated little effect on child maltreatment and its risk factors (Kleavens & Whittaker, 2007)

Need short-term targeted programs and to enhance and

individualize these approaches (Lundahl et al., 2006; Osterling & Austin, 2008)

Other barriers to treatment (transportation, child care,

stigmatizing group setting) (Gopalan et al., 2011; Kemp et al., 2009)

Need to target multiple domains of family functioning by addressing shared etiological factors

Gaps in Extant Child Welfare Interventions

Stress reactivity

Mindfulness

Mindlessness vs. Mindfulness

Form of mental training

A way of becoming aware of what you are experiencing without judging it (Kabat-Zinn & Kabat-Zinn, 1997)

Allows for individuals to develop internal resources: Recognition of automatic

habits Self-regulation of

emotional and physiological reactivity

Promote awareness of distress and its consequences (Garland, 2013)

Mindfulness-Based Interventions

Stress

Negative affect

Coping

Executive Function

Substance use

Trauma-related symptomology

Mental health

Parent-child relationships

Compassion (Dawe & Harnett, 2007; Duncan et al., 2009; Garland et al., 2010; Goldsmith et al., 2014; Kabat-Zinn & Kabat-Zinn, 1997)

Mindfulness Oriented Recovery Enhancement for Child Welfare (MORE-CW)

Overview

Strengths-based & skill-building approach

Cognitive restructuring & positive psychology techniques

Mindfulness training

Core skills: Cognitive reappraisal

Savoring

Mindful breathing

Mindful parenting

Session Format

6 in-home/individual, weekly sessions

Mindful breathing practice

Debrief and process

Psychoeducational content

Experiential mindfulness exercise

Assignment of homework

1) Test the feasibility and acceptability of implementing Mindfulness-Oriented Recovery Enhancement intervention adapted for child welfare (MORE-CW) families

2) Determine the preliminary impact of MORE-CW on family functioning outcomes

3) Identify the cognitive, affective, and psychophysiological mechanisms by which MORE-CW may affect positive changes in parental functioning

Dissertation Aims

Methodology

Data Collection

Sampled parents with current open child welfare cases or who were at risk for CW involvement

Primary inclusion criteria: parental substance use; contact with children

Embedded mixed-methods approach

Quant: Randomized Controlled Trial

Qual: Weekly Session Interviews

Measures

Proximal Outcomes: Stress/ Stress Reactivity (Heart Rate Variability)

Coping

Mindfulness

Parent-Child Relationship

Distal Outcomes: Child Maltreatment

Substance Use

Child Well-Being

Descriptive statistics to examine feasibility and acceptability

Repeated measures ANOVAs to evaluate preliminary treatment outcomes

Template analysis for qualitative data to extract themes for participant experiences

Data Analyses

Sample Characteristics

5

15

60

20

0 20 40 60 80

Race/Ethnicity (%)

Black/African American

Caucasian/White

Latino/Hispanic

Other

5

10

10

35

40

0 10 20 30 40 50

Household income (%)

Less than $15,000

$15,000-$24,999

$25,000-$34,999

$35,000-$44,999

$45,000-$54,999

Feasibility

Assessed for

eligibility/recruited (n=26 )

Excluded (n=6)

Declined to participate or

could not reach

Allocated to intervention (n=11)

Received/ing allocated intervention (n=9) Did not receive allocated

intervention/ drop-out (e.g., “too much

on plate”, personal life changes) (n=2)

Allocated to wait-list control (n=9)

Randomized (n=20)

Allocation

Enrollment

[The program has helped me to] “reduce stress and become more aware of triggers and potentially stressful situations.” [The] “in-home aspect was good because it was easier to relax at home.” “It is better than group because you don’t have to change gears from what one person says to the next. There is more continuity in individual sessions.”

Acceptability

Preliminary Themes

Stress Experiences

Case-related stressors/demands

Threat of foster care

Mandated evaluations/ UAs

Relationship with caseworker

Financial stress

Chronic pain

Use of Mindfulness

Mindful breathing to “step back” and reevaluate the situation

Contemplate reasons to be substance free

Redirect thoughts

Preliminary Trends

30.6 (5.7)

28.2 (4.1)

18.3 (4.8)

20.6 (5.9) 20.7 (5.0)

24.0 (4.1)

0

5

10

15

20

25

30

35

MORE-CW Wait-List

Engagement

Distress

Worry

4.3 (4.6)

1.0 (.63)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Substance Use

Pre

Post

Post Assessment Stress Risk of Substance Use

Preliminary Trends (cont.)

31.5 (5.0)

27.8 (4.3)

31.7 (7.9)

25.4 (4.9)

30.5 (6.2)

23.6 (5.2)

30.8 (6.8)

24.8 (3.7)

23.0 (4.0) 21.8 (1.3)

0

5

10

15

20

25

30

35

MORE-CW Wait-List

Observe

Describe

Awareness

Non-Judge

Non-React

Post Assessment Mindfulness

4.5 (.84)

6.7 (2.1)

0

1

2

3

4

5

6

7

8

Positive Refocusing

Pre

Post

Coping

Internalizing ExternalizingTotal Behavior

Problems

MORE-CW Pre 52.6 56.2 57

MORE-CW Post 47.2 48.6 50.2

Wait-list Pre 59.3 57.3 59.8

Wait-list Post 61.2 57.5 60.8

52.6 56.2 57 47.2 48.6 50.2

59.3 57.3 59.8 61.2 57.5 60.8

010203040506070

Child Behavior Checklist

Preliminary Trends (cont.)

Implications for Promoting Adaptive Functioning for Parents & Children

Redirect attention from treating symptoms of stress to treating underlying causes of stress

Help to maximize parent’s and children’s sense of physical and psychological safety and develop self-regulatory coping skills

Bring awareness to parenting and children’s needs

Increase overall well-being and quality of life

Dawe, S., & Harnett, P. (2007). Reducing potential for child abuse among methadone-maintained parents: Results from a randomized controlled trial. Journal of Substance Abuse Treatment, 32, 381-390. doi: 10.1016/j.jsat.2006.10.003

Dube, S. R., Anda, R. F., Felitti, V. J., Croft, J. B., Edwards, V. J., & Giles, W. H. (2001). Growing up with parental alcohol abuse: Exposure to childhood abuse, neglect, and household dysfunction. Child Abuse & Neglect, 25, 1627-1640.

Duncan, L. G., Coatsworth, J. D., & Greenberg, M. T. (2009). Pilot study to gauge acceptability of a mindfulness-based, family-focused preventive intervention. Journal of Primary Prevention, 30, 605-618. doi: 10.1007/s10935-009-0185-9

Estefan, L. F., Coulter, M. L., Vandeweerd, C. L., Armstrong, M., & Gorski, P. (2013). Relationships between stressors and parenting attitudes in a child welfare parenting program. Journal of Child and Family Studies, 22, 199-208. doi: 10.1007/s10826-012-9569-1

Garland, E. L. (2013). Mindfulness-oriented recovery enhancement for addiction, stress, and pain. Washington DC: NASW Press.

Garland EL, Boettiger CA, Howard MO. (2011). Targeting cognitive-affective risk mechanisms in stress-precipitated alcohol dependence: An integrated, biopsychosocial model of allostasis, automaticity, and addiction. Medical Hypotheses, 76: 745-754.

Garland, E. L., Gaylord, S. A., Boettiger, C. A., & Howard, M. O. (2010). Mindfulness training modifies cognitive, affective, and physiological mechanisms implicated in alcohol dependence: Results of a randomized controlled pilot trial. Journal of Psychoactive Drugs, 42(2), 177-192.

References

Goldsmith, R. E., Gerhart, J. I., Chesney, S. A., Burns, J. W., Kleinman, B., & Hood, M. (2014). Mindfulness-based stress reduction for posttraumatic stress symptoms: Building acceptance and decreasing shame. Journal of Evidence-Based Complimentary & Alternative Medicine, 19, 227-234. doi: 10.1177/2156587214533703 Gopalan, G., Bannon, W., Dean-Assael, K., Fuss, A., Gardner, L., LaBarbera, B.,…McKay, M. (2011). Multiple family groups: An engaging intervention for child welfare-involved families. Child Welfare, 90(4), 135-156. Hanson, R. F., Self-Brown, S., Fricker-Elhai, A. E., Kilpatrick, D. G., Saunders, B. E., & Resnick, H. S. (2006). The relations between family environment and violence exposure among youth: Findings from the National Survey of Adolescents. Child Maltreatment, 11(1), 3-15. Harris-McKoy, D., Meyer, A., McWey, L., Henderson, T. (2013). Substance use, policy, and foster care. Journal of Family Issues, 1-24. Hillson, J.M.C., & Kuiper, N.A. (1994) A stress and coping model of child maltreatment. Clinical Psychology Review, 14(4): 261-285. Kabat-Zinn M, Kabat-Zinn J. (1997). Everyday blessings: The inner work of mindful parenting. New York, NY: Hyperion Kahng, S. K, Oyserman, D., Bybee, D., & Mowbray, C. Mothers with serious mental illness: When symptoms decline does parenting improve? Journal of Family Psychology 2008; 22: 162-166. doi: 10.1037/0893-3200.22.1.162 Kemp, S. P., Marcenko, M. O., Hoagwood, K., & Vesneski, W. (2009). Engaging parents in child welfare services: Bridging family needs and child welfare mandates. Child Welfare, 88(1), 101-126. Klevens, J., & Whitaker, D. J. (2007). Primary prevention of child physical abuse and neglect: Gaps and promising directions. Child Maltreatment, 12(4), 364-377.

References

Lundahl, B. W., Nimer, J., & Parsons, B. (2006). Preventing child abuse: A meta-analysis of parent training programs. Research on Social Work Practice, 16(3), 251-262. Mackinnon, C. E., Lamb, M. E., Belsky, J., & Baum, C. (1990). An affective-cognitive model of mother-child aggression. Development and Psychopathology, 2, 1-13. Marsh, J.C., Smith, B. D., & Bruni, M. (2011). Integrated substance abuse and child welfare services for women: A progress review. Child and Youth Services Review, 33(3): 466-472. doi:10.1016/j.childyouth.2010.06.017 National Center on Addiction and Substance Abuse at Columbia University (CASA). (2005). Family matters: Substance abuse and the American family. Retrieved from http://www.casacolumbia.or/addiction-research/reports/family-matters-substance-abuse-and-american-family Osborne, .C, & Berger, L.M. (2009). Parental substance abuse and child well-being: A consideration of parents’ gender and coresidence. Journal of Family Issues, 30(3): 341-370. doi:10.1177/0192513X08326225 Osterling, K. L., & Austin, M. J. (2008). Substance abuse interventions for parents involved in the child welfare system: Evidence and implications. Journal of Evidence-Based Social Work, 5, 157-189. doi: 10.1300/J394v05n01_07 Patterson, R. G. (1982). A social learning approach: Coercive family process (Vol. 3). Eugene, OR: Castalia. Sinha, R. (2007). The role of stress in addiction relapse. Current Psychiatry Reports, 9(5): 388-395. Wells, K. (2009) Substance abuse and child maltreatment. Pediatric Clinic of North America, 56: 345-362. doi:10.1016/j.pcl.2009.01.006

References