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The Development and Evaluation of an Alcohol and Drug Prevention and Treatment Program for Women and Children
Journal of Substance Abuse Treatment, Vol. 16, No. 3, pp. 265–275, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/99 $–see front matter
PII S0740-5472(98)00049-X
IN THE SPOTLIGHT
The Development and Evaluation of an Alcohol and Drug Prevention and Treatment Program for Women and Children The AR-CARES Program
Little Rock, Arkansas
Abstract – This study examined the evolution of the Arkansas Center for Addictions Research, Education, and Services (AR-CARES) over a 5-year period and evaluated its impact on women and children. The program was designed to provide comprehensive substance use prevention and treatment services to lowincome pregnant and parenting women and their children. The program changed significantly over this time, based upon input from clients and staff, as well as in response to changing community resources. The evaluation suggests that the program had an impact on the substance use of study participants, birth outcomes, and the growth and development of children. © 1999 Elsevier Science Inc. All rights reserved. Keywords – AOD; program development; program evaluation; substance abuse; women’s AOD prevention and treatment.
INTRODUCTION
the fact that drug abuse has historically been seen as a disorder affecting men, and treatment programs in the United States have, therefore, been designed for males. However, surveys show that drug abuse is a problem that many women are facing. According to the 1992 National Household Survey on Drug Abuse, 4.1% of women used an illicit drug during the month before the survey (Center for Substance Abuse Treatment, 1994). The 1992 Pregnancy and Health Survey shows that drug abuse impacts many pregnant women as well. According to that survey, more than 5% of women used an illicit drug at least once during pregnancy, 18.8% of women used alcohol, and 20.4% smoked tobacco (National Institute on Drug
There have been few studies of the effectiveness of substance abuse prevention and treatment programs that serve pregnant or parenting women. In part, this is due to AR-CARES was funded by the Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention Pregnant and Postpartum Women and their Infants demonstration project (H86-SPO4670). Requests for reprints should be addressed to Leanne WhitesideMansell, Center for Research on Teaching and Learning, University of Arkansas at Little Rock, 2801 S. University Avenue, Little Rock, AR 72204. E-mail: [email protected]
Received February 19, 1998; Accepted June 10, 1998.
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Abuse, 1996). In spite of the obvious need, treatment and prevention programs for women, particularly pregnant or parenting women, have often been unavailable. However, in 1989, Congress appropriated funds for the Pregnant and Postpartum Women and Their Infants (PPWI) program, a comprehensive demonstration grant program. One hundred and forty-seven projects have been funded under this program, making it the largest federal program targeting pregnant substance-abusing women and their infants ever funded (Laken & Hutchins, 1996). Evaluation of the effectiveness of these demonstration research and service programs is ongoing. It is believed that pregnant and parenting women need more comprehensive services than have traditionally been offered because these women face unique barriers and treatment needs. There are many reasons that alcohol and drug intervention services are more difficult to obtain for women, particularly pregnant or parenting women, than for men. The sense of shame and guilt may lead women to try to hide their drug problem from family members or friends. In our society, substance abuse by pregnant or parenting women is often viewed as more deviant than drug or alcohol abuse by those not responsible for small children (Finkelstein, 1994). For this reason, women are more likely than men to encounter opposition to treatment from family and friends (Beckman & Amaro, 1986). As the primary caregiver, women are often encouraged to deny the seriousness of their problem in order to remain with their family. Because programs that allow children into residential treatment are scarce, many women fear they will have to give up custody of their children in order to enter treatment (Finkelstein, 1994). Accessible child care for mothers in treatment has been found to be one of the most important services in improving attendance in drug treatment programs (Nelson-Zlupko, Morrison Dore, Kauffman, & Kaltenbach, 1996). Another problem unique to women is the sexual harassment often present in conventional drug treatment programs. In one study, over half of the participants reported at least one episode of sexual harassment that occurred in a treatment facility (Nelson-Zlupko, et al., 1996). Other common barriers that women face when trying to find treatment include lack of transportation, a safe living environment, and financial resources to pay for their treatment (Laken & Hutchins, 1996). In addition to unique barriers, women have alcoholand drug-related issues that are different from those faced by men. One study that highlights the complexity of problems and needs among pregnant substance-abusing women is the California Perinatal Needs Assessment (PNA; Klein, Crim, & Zahnd, 1997). The 401 pregnant women who completed the PNA questionnaire indicated that many have experienced serious negative personal consequences related to alcohol and drug use, including arrest, homelessness, abuse, and feeling suicidal. It is clear that many forms of violence are common in the lives of women who use alcohol and other drugs. Be-
L. Whiteside-Mansell et al.
cause of the high prevalence of sexual abuse in this population, it is believed that women’s drug use may serve as a way to cope with the feelings that follow traumatic experiences (Boyd, 1993; Wadsworth, Spampneto, & Halbrook, 1995; Wilsnack, Vogeltanz, Klassen, & Harris, 1997). Women with addiction problems also reported unmet needs related to parenting, education, vocational training, health care, and child care (Klein et al., 1997). Unique to women are the issues related to their roles as parents and caregivers. Studies have shown that maternal use of drugs is associated with higher levels of parentrelated stress and child maltreatment (Kelley, 1992). Children of substance users are considered to be at increased risk for physical abuse or neglect. One study of a juvenile court sample showed that parents with documented substance abuse were significantly more likely to have had previous charges of child maltreatment, were more likely to have their children permanently removed from their care, and were more likely to reject court-ordered services (Murphy, et al., 1991). Another study of child abuse and neglect cases showed that parental substance abuse greatly increased the likelihood of re-reports for maltreatment to the child protective service agency (Wolock & Magura, 1996). Alcohol and drug prevention and treatment programs for parenting women must also help their clients cope with problems related to prenatal drug exposure in children. These children may face increased risk of health or developmental problems. There are several medical complications that have been associated with prenatal drug exposure, including, neurological impairment, prematurity, low birth weight, fetal alcohol syndrome, sudden infant death syndrome, intrauterine growth retardation, and central nervous system disorders. Other characteristics that have been associated with drug exposure in children include, irritability, hyperactivity, language delays, poor social skills, motor development delays, and feeding difficulties (Chasnoff & Griffith, 1989; Cunningham, 1992; Tronick & Beeghly, 1992; Zuckerman & Bresnahan, 1991). However, particularly regarding research on cocaine abuse during pregnancy, there has been some difficulty separating the effects of cocaine from those of alcohol, other drug, and cigarette use. Other complicating factors include, poor maternal nutrition, the severity and timing of drug use during pregnancy, and the characteristics of the postnatal environment. Researchers are increasingly acknowledging that postnatal environment is important in contributing to the development outcome of drugexposed infants. Because these infants are at high risk for neglectful parenting, family disruption, poverty, violence, abandonment, and homelessness, the impact of their environment on their development cannot be ignored (Bays, 1990; Coles & Platzman, 1993; Hutchings, 1993; Tronick & Beeghly, 1992; Zuckerman & Bresnahan, 1991).
AOD Program for Women and Children
It is believed that appropriate early intervention services and stable home environments can help mitigate some of the effects of prenatal drug and alcohol exposure (Cunningham, 1992). This idea is supported by the findings of Asher Ornoy, Lukashov, Bar-Hamburger, and Harel (1996), who investigated the role of in utero exposure to heroin and the home environment in the developmental outcomes of children born to heroin-dependent parents. They found that when children born to heroin-dependent mothers were divided into those who were raised at home and those adopted, those raised at home functioned significantly lower, and those adopted functioned similarly to controls. Another adoption study involving drug-exposed children (Barth & Needell, 1996) found that at 4 years after placement with adoptive families, the drug-exposed children functioned similarly to controls on behavior reports, school performance, and health scores. These studies are evidence of the important role that the environment can play in children’s development. This research suggests that a nurturing environment can have a positive impact on drug-exposed children, and offers more evidence as to the appropriateness of comprehensive programs for women and their children. These programs can provide the kind of environment that will be conducive to children’s development. In addition, there is also a need for women to receive services in a timely manner. Chasnoff (as cited in Hawley, Halle, Drasin & Thomas, 1995) has found some evidence concerning the possibility of improved outcome for pregnancies in which the mother ceases cocaine use within the first trimester. All of these findings together point to the importance of women and their children receiving timely and appropriate treatment and intervention services. The few studies of comprehensive women’s treatment programs that are available show that programs offering a wide range of services to women are having some success. Outcome data are available from two residential treatment programs: Amity and Olivia’s House. Amity’s Center for Women and Children (Stevens & Arbiter, 1995) provides long-term therapeutic community treatment for addicted pregnant women and women with children. Preliminary outcome data from the Amity program compare outcomes of treatment dropouts and treatment completers. Treatment completers exhibited better outcomes on alcohol and other drug use, re-arrest, employment, and on the use of support groups (Stevens & Arbiter, 1995). Olivia’s House offers residential and outpatient drug users treatment for mothers and their children (Schumacher, Siegal, Socol, Harkless, & Freeman, 1996). Services offered by Olivia’s House include, case management, crisis intervention, detoxification, residential care, childcare, and outpatient aftercare services. The evaluation of Olivia’s House is ongoing, but preliminary findings indicate that the program is having a positive impact. Comparisons of Addiction Severity Index (McLellan et al., 1992) ratings for treatment completers from intake to discharge reveal reductions in severity for alcohol
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and drug abuse, psychiatric problems, and family/social problems. In addition, results from the Parenting Stress Index reveal that approximately half of treatment completers experienced significant reductions in parenting stress (Schumacher, et al., 1996). Two nonresidential programs designed to address the needs of pregnant substance-abusing women in a “onestop shopping” model of care are the CHANCES program and the Centers for Addiction and Pregnancy (CAP). The CHANCES program offers coordinated primary care in a single location through a team of nurses, addiction counselors, child-care specialists, a physician, a social worker, and a peer counselor (Tanney & Lowenstein, 1997). Compared to women who entered the program after giving birth, women who received prenatal care through CHANCES had fewer positive toxicologies at delivery, infants with higher birthweights, and more infants born after 36 weeks gestation. In addition, from pretest to posttest, women scored better on four parenting variables: expectations, empathy, corporal punishment, and role reversal (Tanney & Lowenstein, 1997). The CAP program offers women mental health/substance use treatment, obstetric/gynecological care, family planning, pediatrics, transportation, nutritional support, and childcare services (Jansson, Svikis, Lee, Paluzzi, Rutigliano, & Hackerman, 1996). Comparing CAP participants to matched controls, infants of controls were 2.5 times more likely to require neonatal intensive care unit (NICU) admission, and their average length of stay was 6 times longer than infants of treatment participants. In addition, infants of participants were examined using the Bayley Scales of Infant Development at 6, 12, and 24 months and were found to be generally within normal limits of development (Jansson et al., 1996). This study evaluated and examined the evolution of a comprehensive women’s intervention program directed at decreasing maternal substance use and lessening addiction’s harmful effects on pregnancy and postpartum women and their infants. In addition to the detailed examination of the evolution of the program, three empirical research questions were addressed. Although pregnant and parenting women with addiction problems were recruited into the program, this evaluation focused on pregnant entrants and children born during program participation. This focus allowed this study to address the following important questions: (a) Did the intervention result in a sustained decrease in alcohol and other drug use among pregnant women between intake and delivery? (b) Were the birth outcomes improved and obstetric/neonatal complications reduced by program participation? (c) Did women that participated in the program during pregnancy have children with normal growth and development? PROGRAM DESCRIPTION AND EVOLUTION The Arkansas Center for Addictions Research, Education, and Services (AR-CARES) located in Little Rock is
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a licensed facility that (a) provides residential and outpatient substance abuse prevention and treatment services to low-income pregnant and parenting women and their children, and (b) provides leadership to improve and change the system of care for addicted mothers and their families. AR-CARES was established as a 5-year Center for Substance Abuse Prevention (CSAP) PPWI demonstration project. The goals of this 5-year project were to improve the growth and development of the children of clients served, support the client in recovery from substance abuse, and to develop the structure to provide and expand a quality program after initial funding ended.
The Planned Program The model prevention and treatment program was initially planned as a 4 and 1/2 hours per day, 5 days per week, intensive outpatient program based on Miller’s self-in-relation theory as adapted by Finkelstein (1996) through her work with addicted mothers at the Center for Addiction, Pregnancy, and Parenting in Cambridge, MA. This model emphasizes the importance of relationships in the lives of pregnant and parenting women and the need to include relational issues in the treatment program. As a part of their treatment, women need to learn to participate in satisfying and supportive relationships. Table 1 lists the services available at the beginning to the program. The intensive phase of the program was designed to last for at least 12 weeks and serve 9 to 12 women at any one time. The clinical facility was administratively located within the Department of Obstetrics and Gynecology at the state’s only medical university and it was expected that this would be the source of the majority of client referrals. It was physically located in a tree-lined, off-campus facility in a stable, racially mixed neighborhood. As much as possible, the program was to be a “onestop shopping” model implemented by a multidisciplinary team and guided by an individualized treatment plan. On-site services planned, in addition to education and counseling, included 24-hour on-call clinical staff, prenatal care, and Women, Infants, and Children (WIC) services. It was planned that referrals would be made as needed for hospitalization, specialized services for program infants/children, and for birth-related hospitalizations. The plan for clinical services delivery included a team approach, using a master’s-level social worker, master’slevel nurse practitioner, case managers, and consultants in medicine (obstetrics, pediatrics, psychiatry), addictions, psychology, and law/ethics. The project director was to serve as team leader. Biweekly group sessions were to be held with the mother’s family of choice regarding recovery issues for pregnant and parenting women and focusing on issues ranging from communication skills to the 12-step recovery program (Table 1).
L. Whiteside-Mansell et al. TABLE 1 Initial Services of Outpatient Program for Women and Children
4–5 hour treatment day Assistance in locating child care in the community, as needed Alcohol and drug use assessment Education and treatment Mental health assessment and referral Life skills assessment and development Group and individual counseling, covering the following areas: Denial The disease process of addiction Physiology and pharmacology of tobacco, alcohol, and other drugs Effect of tobacco, alcohol, and other drugs on the mother and fetus Maternal–fetal/infant bonding Parenting the drug-exposed infant Women in relationships Women’s issues in recovery Loss and grief Anger and blame Family dynamics in recovery 12-step recovery Self-esteem building Relapse prevention AIDS and other sexually transmitted diseases Preterm-birth prevention Preparation for labor and delivery Family planning Child development and care Parenting education and support Health services, including: Prenatal care Delivery services Postpartum and interconceptional care Child health services Health education, including: Prenatal Infant health and development Nutrition Child safety Labor and delivery Family planning Prevention of sexually transmitted disease Service coordination
Barriers Although a preliminary study had shown a clear need for a treatment program in the community, the number of initial participants was about half of the number expected. Input from clients, staff, and applicants resulted in the identification of three primary barriers: lack of child care, lack of transportation, and lack of safe, drugfree housing. The project had planned to place infants in existing child-care centers, but found no funding for child-care existed. In addition, child-care regulations prevented the entry of an infant under 6 weeks old into a licensed childcare facility. Transportation was to be provided by the
AOD Program for Women and Children
Red Cross Wheels Program; however, a local transit contract prohibited Red Cross from contracting with us. Housing was a particular problem. The one homeless shelter that accepted children required women to attend their program even though it did not include drug abuse treatment. Many clients were living in housing that was temporary, unstable, or that included other residents who did not support the client seeking treatment. In short, the target population of women did not have the social supports required to attend a structured 4–5-hour per day outpatient program.
Program Service Changes Because there was both administrative and staff support to develop a program that met client needs, services were dynamic throughout the project, with additional funding sought to provide additional services. Over the course of the project, on-campus residential support services were obtained to house 13 families at one time. The majority of women entering the program elected residential support services. The average stay in the intensive phase was 15 weeks. However, many families (60%) left by the end of 4 weeks, while another group (33%) stayed more than 2 months. A few received residential support services for longer than a year. By the end of the project, AR-CARES was advocating more community-based and in-home services, recognizing the need for short-term “crisis” residential support for some families, but also the treatment value of having families in their own homes as quickly as possible. Federal and state welfare reform efforts accented this need to provide community-based services that hastened a mother’s successful employment and independent living. The recent movement away from long-term residential support moves the program closer to its original outpatient design. The addition of residential services allowed the program to address another problem with the initial plan. A need was seen to extend the treatment day to 7 to 8 hours per day. Additional educational sessions included art class, center- and home-based nutrition classes, mother– child play groups, and vocational activities. In response to the failure of the original plans for child care, the program added an on-site infant/toddler nursery program run by a half-time supervisor and volunteer staff. By the end of the fifth year, the children’s program was a licensed facility serving up to 40 children, ranging in age from newborn through 12 years. Open from 7:30 am until 9:00 pm, the child-care center maintains a high staff-to-child ratio and draws on community resources to provide on-site occupational, physical, and speech therapy. To address the transportation problem, a minivan was purchased. Clients with Medicaid were encouraged to access transportation through private Medicaid vendors
269 TABLE 2 Service Additions to Treatment Program by the Fifth Year
7–8 hour treatment day On-site residential support Licensed early intervention services On-site licensed child care Infant and toddler Preschool, school age School age summer program Entrepreneurial skills/vocational education Art classes Community 12-step meeting attendance Cooperative extension services – life skills Off-site residential support Employment skills and counseling Licensed mental health services for client, child, and family On-site evening outpatient treatment/transitional services Transportation Tobacco-free environment
or taxis. The third year of the program another 15 passenger van was added. Table 2 lists additional services offered 5 years after the program began. In addition, existing services changed in content and delivery during the program. For example, based on client and staff report, parent education moved away from didactic parenting education sessions to more mother–child activities. This was also supported by stipends that allowed transitioning clients to work in the on-site child-care center under supervision. Another significant change was seen in the shift from individual treatment plans to individualized family treatment plans. By integrating a mother’s care with that of her child(ren), improved individual and family outcomes were expected. As a result, the state is seeking a Medicaid waiver to cover “family treatment and rehabilitation for addicted women and their children” under an innovative managed-care concept that would pay a capped global family treatment rate. The available health care was expanded with a health clinic that provided prenatal, postpartum, and interconceptional care (Table 2) to mothers participating in the program. Children’s health services included neonatal checkups, child health supervision at an enhanced schedule, and immunizations for target infants. In addition, onsite mental health services and transition services in the evening were made for clients who no longer receive full-day treatment because of school or work commitments. Another change from the initial plan was the source of referrals. Perhaps because of a lack of leadership commitment, referrals did not come as expected from the obstetrics clinic at the medical school. Instead, women were referred to the program from health care, alcohol and drug treatment, child welfare, social services, and criminal justice providers, as well as community-based organizations, family members, and self-referrals.
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METHODS Study Design The ideal design for determining the effects of intervention is an experimental design involving random selection from the population and random assignment of potential participants to intervention and control groups. Such a design was not ethical, nor practical, in part because state regulations require the AR-CARES program to be available to all eligible participants. In an effort to partially compensate for our inability to employ a true experimental design, a quasi-experimental design was used that involves a nonparticipating group. In addition, child growth and development data were collected at multiple points and compared with published normative data. In order to evaluate the effectiveness of the intervention, it is important to examine the degree to which findings converge (from both between- and within-group comparisons) and the degree to which those findings are consistent with expectations. The nonparticipating group included pregnant women who were invited into the study but refused services. The inclusion of this nonparticipating group of women and children in the study allowed an examination of birth outcomes for both women and children and later development for children, as well as an examination of patterns of maternal substance use. While nonparticipating mothers were expected to be similar in some aspects, because differences may exist, data were collected at study intake to compare the two groups on an array of characteristics. Women were interviewed at study intake, the delivery of the target child, and when the target child was 6, 12, and 18 months of age. Delivery data were also obtained by an examination of hospital records. Maternal interviews and child development data were collected in a clinical setting by trained clinical staff. A urine toxicology was obtained at intake and delivery on participating and nonparticipating mothers and infants. For participating women, urine toxicology screens were also obtained several times randomly during the period between study intake and delivery. All infant development data were obtained by a clinician or research assistant meeting standards set by a CSAP national cross-site study. As part of this cross-site study, all data collectors were trained and certified to meet national standards. The Bayley Scales of Infant Development (Bayley, 1969) are designed to provide a basis for the evaluation of a child’s developmental status in the first 2 1/2 years of life. The Mental Scale is designed to assess sensory-perceptual acuities, discriminations, and the ability to respond to these; the early acquisition of “object constancy” and memory, learning, and problem-solving ability; vocalizations and the beginnings of verbal communication; and early evidence of the ability to form generalizations and classifications. Results of the administration of the Mental Scale are expressed as a
standard score, the Mental Development Index (MDI). The Motor Scale is designed to provide a measure of the degree of control of the body, coordination of the large muscles and fine manipulatory skills of the hands and fingers. Results of the administration of the Motor Scale are expressed as a standard score, the Psychomotor Development Index (PDI). The standard scores are normalized to have a mean of 100 and a standard deviation of 15. Sample Description Data concerning current and past alcohol and other drug (AOD) use were obtained from 72 participating women and 23 nonparticipating women at study intake. Delivery assessments were obtained for 27 participating women and 10 nonparticipating women. Table 3 provides demographic information for participating and nonparticipating women. As can be seen by these characteristics, the majority (75%) of participants in this study were African American women in their late to mid-20s who were not married (most had never been married). Although most had not completed high school, about a fourth had completed their general equivalency diploma (GED). Few (3%) were employed when they entered the study, however, most (80%) had worked at a job during the previous 5 years. About one third of the women had legal issues surrounding child protective services (DCFS case open) at the time of intake into the study. Nearly all women reported a history of victimization. Most reported a history of sexual, physical, and emotional abuse. The majority also reported a family history of alcohol and drug use, as well as a previous (or current) partner that used. Many also had a history of prior alcohol or other drug (AOD) treatment. Of the women entering program, 32.4% were required by legal agencies to attend. Women were enrolled an average of 13.6 (SD 5 8.4) weeks before the delivery of their child. Five women enrolled only about 2 weeks before delivery of the target child. The longest time between intake and delivery was 26 weeks. Comparison of Participating and Nonparticipating Women Participating and nonparticipating women were compared on a variety of characteristics and initial status variables. Participating and nonparticipating women appear to be similar in most ways in demographic characteristics and resources. The two groups of women did not differ in the amount, type, or consequences of AOD use at intake. No differences were found between participating and nonparticipating women in their reported history of coresidency with AOD users, victimization, or legal involvement. No differences were seen between the two groups in their self-reported barriers to accessing care.
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TABLE 3 Initial Demographic Description of Participating and Nonparticipating Women as Percent or Mean
Characteristic
Average age (years) Marital status Married Never married Race (African American) GED complete Average level of education (years) Average income per month Current AOD use by partner Current DCFS case open History of victim of abuse Rape Incest Physical abuse Childhood abuse Emotional abuse History of arrested History of treatment Residential treatment History of family AOD Week of pregnancy at intake Average number of previous births
Participating Women (n 5 72)
Nonparticipating Women (n 5 23)
M 5 28.8, SD 5 5.2
M 5 26.3, SD 5 5.2
11.6% 60.9% 75% 20.0% M 5 11.1, SD 5 1.7 M 5 $268.0, SD 5 $279 65.5% 31.4%
17.4% 60.9% 70% 23.8% M 5 11.6, SD 5 1.9 M 5 $192.0, SD 5 $309 68.8% 11.8%
40.6% 21.9% 71.9% 30.3% 72.7% 71.4%
63.2% 42.1% 75.0% 31.6% 78.9% 85.7%
60.0% 80.0% M 5 24.2, SD 5 10.4
42.8% 90.0% M 5 23.8, SD 5 10.9
M 5 2.8, SD 5 2.2
M 5 1.6, SD 5 1.3
AOD 5 Alcohol or other drugs; DCFS 5 Department of Child and Family Services; GED 5 General Equivalency Diploma.
RESULTS Examination of AOD Use Table 4 shows the percent of women that reported the use of substances at intake, and delivery assessments. At intake, most clients reported the use of alcohol or other substance use. For example, 85% reported the use of marijuana, 40% the use of cocaine, 90% the use of crack, and 15% reported the use of amphetamines. By the time of the birth of their child, the numbers of participating women and nonparticipating women reporting the use of alcohol dropped significantly, based on paired t-tests. As seen in Table 4, 83.6% of participating women reported alcohol use at intake and only 4% reported any use between intake and delivery. This is a significant reduction in the proportion of alcohol users among participating women (t 5 29.3, p 5 .001). The drop in the number of nonparticipating women (90.5% to 33%), while statistically significant (t 5 24.6, p 5 .003), was not as dramatic. Although the number of both participating and nonparticipating women reporting continued alcohol use declined, the number of participating women reporting alcohol use declined significantly more than nonparticipating women (x2 5 5.4 p 5 .02). Among the women that reported drinking alcohol during the last 3 months, no differences were found between participating and nonparticipating women, with both reporting about 3 drinks a day.
At the time of the birth of their child, the number of participating and nonparticipating women reporting other drug use dropped significantly, based on paired t-tests. At intake, 91.7% of pregnant participating women reported other drug use; at delivery only 3.7% reported continued drug use. This is a significant reduction in the proportion of substance use among participating women (t 5 225.0 p 5 .001). Of the 95.7% of nonparticipating women reporting other drug use at intake, significantly fewer (33.3%) reported continued use at delivery (t 5 TABLE 4 Percent of Participating and Nonparticipating Women Reporting Alcohol, Other Drug, and Tobacco Use
Substance
Alcohol Intake Delivery Other drug use Intake Delivery Tobacco Intake Delivery
% Participating Women (n 5 72)
% Nonparticipating Women (n 5 23)
83.6 4.0*,**
90.5 33.3*,**
91.7 3.7*,**
95.7 33.3*,**
67.0 55.6**
88.0 90.0**
* p , .05 between intake and delivery assessments. ** p , .05 between participating and nonparticipating.
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L. Whiteside-Mansell et al. TABLE 5 Number and Percent of Women Experiencing Obstetric/Neonatal Complications by Participating and Nonparticipating Women
Participating Complications
Total reporting Any type of complication Placental abruption Maternal infection Premature labor Preeclampsia Fetal distress Meconium-stained amniotic fluid Other
Nonparticipating
n
%
n
%
27 12 1 3* 2* 1 2 6 4
46 4 11 7 4 7 23 15
10 4 0 4* 4* 0 0 1 1
40 0 40 40 0 0 10 10
* p , .05.
23.4, p 5 .01). Similar to the reports of alcohol use, participating women reported significantly less use of other substances than nonparticipating women at delivery (x2 5 5.3, p 5 .02). The results of urine toxicology analyses appear to support the self-report of women concerning their use of substances. Twenty-five participating women received a total of 135 urine screens during the period between study intake and delivery—an average of 4.9 screens each. Of these only two were positive. Infants also received urine screens at birth. Of the 21 infants of participating women assessed, 1 had a positive urine test, 2 of the 9 nonparticipating infants were positive. The number of participating women reporting tobacco use at delivery was significantly less than the number reporting tobacco use at intake (p 5 .01). This was not true for nonparticipating women. All six of the nonparticipating women who reported tobacco use at intake continued its use at delivery. Significantly more nonparticipating women reported smoking at the time of delivery than participating women (p 5 .05). When the number of cigarettes smoked a day are examined, participating women reported smoking significantly fewer cigarettes than nonparticipating women (p 5 .02). For example, when all women in both groups are considered, participating women report smoking 3.4 (SD 5 4.3) cigarettes a day and nonparticipating women report 8.1 (SD 5 6.5) cigarettes a day. Among the women in each group who reported smoking (excluding women that do not smoke), the difference in the number approaches significance (p 5 .096). For this subgroup of women who smoked, participating women smoked an average of 6.8 cigarettes (SD 5 3.6) per day and nonparticipating women smoked an average of 10.4 (SD 5 5.4). Birth Outcomes The data suggest that program participation may have resulted in fewer complications of specific types of birth. Outcome data were examined in independent t-tests between
participating and nonparticipating women. In addition, ordinary least squares linear regression was used to examine the impact of the length of participation on outcome measures. For these analyses, nonparticipating women were considered to have zero length of participation. As can be seen in Table 5, the rate of complications was similar (about 40–46%) for participating (n 5 12) and nonparticipating (n 5 4) women. However, significantly fewer participating women experienced premature labor (p 5 .02) and maternal infection (p 5 .05) than nonparticipating women. No differences were seen when the length of participation was examined. As shown in Table 6, participating mothers stayed in the hospital an average of 2.3 days after the birth of the target child compared to an average of 5 days for nonparticipating mothers (t 5 22.2, p 5 .03). These analyses included one nonparticipating women with an exceptionally long hospital stay of 21 days. When this subject is excluded from the analyses, the length of stay is no longer statistically different. The number of infant hospital days after the delivery is not different for children of participating and nonparticipating women. No statistically significant differences were found between infants of participating and nonparticipating women in the incidence (11% and 40%, respectively) or duration of neonatal intensive care unit (NICU) treatment (.44 and .88 days, respectively). No differences were seen when the length of participation was examined. Infant birthweight was similar for each group when compared with independent t-tests. However, when length of time between program intake and the birth of the child is taken into account, longer program participation is associated with larger birthweight (F 5 5.08, p 5 .03, explaining 13% of the variance). No statistical differences were found in the length of the infants in each group. Although the difference did not reach the .05 significance level, infants of participating women tended to have larger head circumferences (35 cm as compared with 33 cm; t 5 21.9, p 5 .07). One-minute and 5-minute Apgar scores were similar for both groups of infants. The
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TABLE 6 Maternal and Infant Health Markers at Delivery by Participating and Nonparticipating Women
Participating Delivery Information
Number of maternal hospital daysa Number of infant hospital daysb Number of days in NICUc Infant weight Infant length (inches) Infant head circumference (centimeters) 1-minute Apgar score 5-minute Apgar score Weeks of gestation at delivery
Nonparticipating
M
SD
M
SD
2.3* 3.1 .4 6.5* 18.7 35** 8 8 38*
1.2 2.0 1.4 1.4 2.1 3.6 1.6 1.6 2.7
5* 4 .8 5.8* 19.8 33** 8 9 36*
5.9 4.0 2.2 1.1 .8 .7 1.8 .5 2.6
NICU 5 neonatal intensive care unit. a Includes one nonparticipating woman with a 21-day hospital stay. Excluding this extreme observation, nonparticipating women had a mean hospital stay of 3 days. b Includes an infant of a nonparticipating woman with a 14-day hospital stay. With that infant excluded the mean is 3. c Three infants of participating women and two infants of a nonparticipating woman had NICU days. Of these five, the mean NICU stay was 4 days for other groups. * p , .05. ** p , .10.
gestational age of infants of participating women was 2 weeks more than infants of nonparticipating women. This was found both in the t-test analysis (t 5 2.2, p 5 .03) and the examination of length of participation analysis (F 5 5.27, p 5 .03).
At 6 months of age, development measures for all children assessed were within normal ranges. Although one child of a participating mother scored in the 5th percentile for growth at 6 months, on average, children of both participating and nonparticipating women were in normal ranges. Too few children of nonparticipating clients were assessed at 6 months to perform reliable statistical tests. At 12 months of age, all of the children of participating women still scored in the normal range for cognitive development, however, one child of a nonparticipating
Child Growth and Development Table 7 shows growth and development markers for children of both participating and nonparticipating women.
TABLE 7 Mean, Minimum, and Maximum Growth and Development Scores by Participating and Nonparticipating Groups
Participating Assessment Time
6 Month Bayley MDI Bayley PDI Weight percentile Length percentile Head circumference percentile 12 Month Bayley MDI Bayley PDI Weight percentile Length percentile Head circumference percentile 18 Month Bayley MDI Bayley PDI Weight percentile Length percentile Head circumference percentile
Nonparticipating
Number of Children
Average
Minimum/Maximum
Number of Children
Average
Minimum/Maximum
16 16 7 7 7
99.38 98.38 36.43 36.43 47.14
92/107 72/114 5/75 5/75 5/75
3 3 2 2 2
100.00 102.00 17.50 17.50 17.50
94/104 100/104 10/25 10/25 10/25
9 9 5 5 5
98.22 101.11 50.00 55.00 55.00
84/127 89/109 25/100 25/75 25/100
5 5 3 2 2
89.80 95.00 11.67 10.00 15.00
69/102 79/113 5/20 10/10 5/25
6 6 2 2 2
91.71 97.50 25.00 37.50 37.50
79/103 82/107 25/25 25/50 25/50
1 1 1 1 1
79.00 79.00 10.00 10.00 5.00
79/79 79/79 10/10 10/10 5/5
MDI 5 Mental Development Index; PDI 5 Psychomotor Development Index.
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woman scored below the normal range for both PDI (79) and MID (69) Bayley subscales. Independent t-tests were used to compare the cognitive scores for children of participating and nonparticipating women. There were no statistical differences between the two groups on cognitive development scores. Growth measures for children of participating women indicate that these children are within normal ranges, however, none of the three children of nonparticipating women showed growth markers above the 25 percentile. These differences could not be reliability tested because of the low number of assessments obtained for children of nonparticipating women. At 18 months of age, a similar pattern continued in the cognitive development, as was seen at 12 months of age. It was not possible to perform statistical tests of scores because only one child of a nonparticipating woman was assessed and only two participating children were assessed for growth. However, it can be noted that all of the children of participating women were within normal ranges for both growth and development.
DISCUSSION This study examined the evolution of the AR-CARES over a 5-year period and evaluated it’s impact on women and children. The program changed significantly over this time, based upon input from clients and staff, and in response to changing community resources. Program participants and staff saw the program’s ability to remain flexible enough to respond to emerging opportunities to better serve the target population as a strength. This flexibility allowed the addition of services such as residential facilities, mental health counseling, child care, early intervention for children, and transportation. Although the program was effective in influencing maternal health and social outcomes, this study only examined maternal AOD use, pregnancy outcomes, early infant health, and infant development status. An examination of the outcomes for women and children who participated in the program compared to women and children that did not suggests that the program had a positive impact. The reduction of AOD use was associated with improvements in birth outcomes and living environments for infants of participating mothers. Program participation was associated with a significant reduction in substance use during the time before the birth of the target child. Participating women had a lower incidence of premature labor and maternal infections. Infants of women that participated in the program had higher gestational ages. When the length of participation was considered, infants of women that participated had significantly higher birthweights than infants of nonparticipating women. Birthweight and gestational age are key indicators of later health. In particular, low birthweight infants are at a greater risk for death and long-term health and developmental disabilities than normal birthweight infants.
On average, nonparticipating women also had longer maternal hospital stays after delivery. Although this finding is driven by the stay of one nonparticipating woman, this is the exception that the program is intended to prevent. Although there were not statistical differences found between the number of infant hospital days of NICU days, this is in part due to a lack of power to detect differences. Infants of participating women tended to have shorter hospital days. There are also indications that the program may have had an impact on later child development. Children of women who participated in the program had normal growth and cognitive development on standardized measures. Because there were very few follow-up assessments made with nonparticipating children, it was not possible to meaningfully compare growth and development between children of participating and nonparticipating women. However, as would be expected, some children of nonparticipating women were not in the normal ranges for growth and development. Because all children were prenatally exposed to substances, there is some support for the hypotheses that the impact of the early home environment and parenting may be protective for many children. Three important factors may have prevented this study from showing more conclusive results. First, the length of this study did not allow for a later follow-up. It is possible that the impact of the program may be strongest in the behavioral development of children in more formal settings like kindergarten. Second, the number of follow-up assessments were small and provided limited power for statistical analysis. However, the findings converge (birth outcomes and later development) and are consistent with expectations. In addition, even where statistical significance was not found the trend of the results are consistent with other findings that were statistically significant. Finally, there were large variations in the amount of participation by women. Women that entered the program only 2 weeks before the birth of their child were included with women that enrolled 26 weeks before delivery. However, the results of this study suggest that longer participation may result in more positive birth outcomes. For example, the length of participation was predictive of birthweight and gestational age. Although the program staff made efforts to recruit women early in their pregnancy, because the program was new and many links with other agencies had to be established, they were not always successful. Because the statistical tests employed in this study assume an experimental design, the lack of randomization in this study is also a limitation. However, this problem is alleviated to some degree by the finding that women who participated and women who did not were similar on a wide variety of characteristics. It is possible that the groups were different on some characteristic not measured. However, these differences may have impacted the result in either positive or negative ways. For exam-
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ple, it is possible that participating women were more motivated than nonparticipating women. On the other hand, it is likely that the nonparticipating women available for assessment were the most stable of this group and perhaps the women most likely to have positive outcomes. It is important to note that in spite of the lack of power associated with small samples and other limitations that might lead to a lack of findings, positive differences were found. This is due, in part, to the dynamic process this program used to respond to client needs and changing community resources. Leanne Whiteside-Mansell, EdD* Cynthia C. Crone, MNSc† and Nicola A. Conners, MEd‡ *University of Arkansas at Little Rock, Little Rock, AR †University of Arkansas for Medical Sciences, Little Rock, AR ‡University of Memphis, Memphis, TN REFERENCES Asher Ornoy, V.M., Lukashov, I., Bar-Hamburger, R., & Harel, S. (1996). The developmental outcome of children born to heroindependent mother, raised at home or adopted. Child Abuse and Neglect, 20, 385–396. Barth, R.P., & Needell, B. (1996). Outcomes for drug-exposed children four years post-adoption. Children and Youth Services Review, 18, 37–56. Bayley, N. (1969). Bayley Scales of Infant Development. New York: Psychological Corporation. Bays, J. (1990). Substance abuse and child abuse. Pediatric Clinics of North America, 37, 881–903. Beckman, L.J., & Amaro, H. (1986). Personal and social difficulties faced by women and men entering alcoholism treatment. Journal of Studies on Alcohol, 47, 135–145. Boyd, C.J. (1993). The antecedents of women’s crack cocaine abuse: Family substance abuse, sexual abuse, depression and illicit drug use. Journal of Substance Abuse Treatment, 10, 433–438. Center for Substance Abuse Treatment. (1994). Practical approaches in the treatment of women who abuse alcohol and other drugs. (DHHS No. 94-3006). Washington, DC: U.S. Government Printing Office. Chasnoff, I.J., & Griffith, D.R. (1989). Cocaine: Clinical studies of pregnancy and the newborn. Annals of the New York Academy of Sciences, 562, 260–266. Coles, C.D., & Platzman, K.A. (1993). Behavioral development in children prenatally exposed to drugs and alcohol. The International Journal of the Addictions, 28, 1393–1433. Cunningham, R. (1992). Developmentally appropriate psychosocial care for children affected by parental chemical dependence. Journal of Health Care for the Poor and Underserved, 3, 208–221. Finkelstein, N. (1994). Treatment issues for alcohol- and drug-dependent pregnant and parenting women. Health and Social Work, 19, 7–15. Finkelstein, N. (1996). Using the relational model as a context for treating pregnant and parenting chemically dependent women. Journal of Chemical Dependency Treatment, 6, 23–44.
275 Hawley, R.L., Halle, T.G., Drasin, R.E., & Thomas, N.G. (1995). Children of addicted mothers: Effects of the “crack epidemic” on the caregiving environment and the development of preschoolers. American Journal of Orthopsychiatry, 65, 364–379. Hutchings, D.E. (1993). The puzzle of cocaine’s effects following maternal use during pregnancy: Are there reconcilable differences? Neurotoxicology and Teratology, 15, 281–286. Jansson, L.M., Svikis, D., Lee, J., Paluzzi, P., Rutigliano, P., & Hackerman F. (1996). Pregnancy and addiction. Journal of Substance Abuse Treatment, 13, 321–329. Kelley, S.J. (1992). Parenting stress and child maltreatment in drugexposed children. Child Abuse and Neglect, 16, 317–328. Klein, D., Crim, D., & Zahnd, E. (1997). Perspectives of pregnant substance-using women: Findings from the California Perinatal Needs Assessment. Journal of Psychoactive Drugs, 29, 55–65. Laken, M.P., & Hutchins, E. (1996). Recruitment and retention of substance-using pregnant and parenting women: Lessons learned. Arlington, VA: National Center for Education in Maternal and Child Health. McLellan, A.T., Cacciola, J., Kushner, H., Metzger D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M. (1992). The Fifth Edition of the Addiction Severity Index: Cautions, additions, and normative data. Journal of Substance Abuse Treatment, 9, 192– 199. Murphy, J.M., Jellinek, M., Quinn, D., Smith, G., Poitrast, F.G., & Goshko, M. (1991). Substance abuse and serious child mistreatment: Prevalence, risk, and outcome in a court sample. Child Abuse and Neglect, 15, 197–211. National Institute on Drug Abuse. (1996). National pregnancy and health survey: Drug use among women delivering livebirths: 1992 (NIH No. 96-3819). Rockville, MD: National Institutes of Health. Nelson-Zlupko, L., Morrison Dore, M., Kauffman, E., & Kaltenbach, K. (1996). Women in recovery: Their perceptions of treatment effectiveness. Journal of Substance Abuse Treatment, 13, 51–59. Schumacher, J.E., Siegal, S.H., Socol, J.C., Harkless, S., & Freeman, K. (1996). Making evaluation work in a substance abuse treatment program with children: Olivia’s house. Journal of Psychoactive Drugs, 28, 73–83. Stevens, S.J., & Arbiter, N. (1995). A therapeutic community for substance-abusing pregnant women and women with children: Process and outcome. Journal of Psychoactive Drugs, 27, 49–56. Tanney, M.R., & Lowenstein, V. (1997). One-stop shopping: Description of a model program in provide primary care to substance-abusing women and their children. Journal of Pediatric Health Care, 11, 20–25. Tronick, E.Z., & Beeghly, M. (1992). Effects of prenatal exposure to cocaine on newborn behavior and development: A critical review. In Identifying the needs of drug-affected children: Public policy issues (DHHS Publication No. 92-1814, pp. 93–108). Washington, DC: U.S. Department of Health and Human Services. Wadsworth, R., Spampneto, A. M., & Halbrook, B.M. (1995). The role of sexual trauma in the treatment of chemically dependent women: Addressing the relapse issue. Journal of Counseling and Development, 73, 401–406. Wilsnack, S.C., Vogeltanz, N.D., Klassen, A.D., & Harris, T.R. (1997). Childhood sexual abuse and women’s substance abuse: National survey findings. Journal of Studies on Alcohol, 58, 264–271. Wolock, I., & Magura, S. (1996). Parental substance abuse as a predictor of child maltreatment re-reports. Child Abuse and Neglect, 20, 1183–1193. Zuckerman, B., & Bresnahan, K. (1991). Developmental and behavioral consequences of prenatal drug and alcohol exposure. Pediatric Clinics of North America, 38, 1387–1406.
PII S0740-5472(98)00049-X
IN THE SPOTLIGHT
The Development and Evaluation of an Alcohol and Drug Prevention and Treatment Program for Women and Children The AR-CARES Program
Little Rock, Arkansas
Abstract – This study examined the evolution of the Arkansas Center for Addictions Research, Education, and Services (AR-CARES) over a 5-year period and evaluated its impact on women and children. The program was designed to provide comprehensive substance use prevention and treatment services to lowincome pregnant and parenting women and their children. The program changed significantly over this time, based upon input from clients and staff, as well as in response to changing community resources. The evaluation suggests that the program had an impact on the substance use of study participants, birth outcomes, and the growth and development of children. © 1999 Elsevier Science Inc. All rights reserved. Keywords – AOD; program development; program evaluation; substance abuse; women’s AOD prevention and treatment.
INTRODUCTION
the fact that drug abuse has historically been seen as a disorder affecting men, and treatment programs in the United States have, therefore, been designed for males. However, surveys show that drug abuse is a problem that many women are facing. According to the 1992 National Household Survey on Drug Abuse, 4.1% of women used an illicit drug during the month before the survey (Center for Substance Abuse Treatment, 1994). The 1992 Pregnancy and Health Survey shows that drug abuse impacts many pregnant women as well. According to that survey, more than 5% of women used an illicit drug at least once during pregnancy, 18.8% of women used alcohol, and 20.4% smoked tobacco (National Institute on Drug
There have been few studies of the effectiveness of substance abuse prevention and treatment programs that serve pregnant or parenting women. In part, this is due to AR-CARES was funded by the Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention Pregnant and Postpartum Women and their Infants demonstration project (H86-SPO4670). Requests for reprints should be addressed to Leanne WhitesideMansell, Center for Research on Teaching and Learning, University of Arkansas at Little Rock, 2801 S. University Avenue, Little Rock, AR 72204. E-mail: [email protected]
Received February 19, 1998; Accepted June 10, 1998.
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Abuse, 1996). In spite of the obvious need, treatment and prevention programs for women, particularly pregnant or parenting women, have often been unavailable. However, in 1989, Congress appropriated funds for the Pregnant and Postpartum Women and Their Infants (PPWI) program, a comprehensive demonstration grant program. One hundred and forty-seven projects have been funded under this program, making it the largest federal program targeting pregnant substance-abusing women and their infants ever funded (Laken & Hutchins, 1996). Evaluation of the effectiveness of these demonstration research and service programs is ongoing. It is believed that pregnant and parenting women need more comprehensive services than have traditionally been offered because these women face unique barriers and treatment needs. There are many reasons that alcohol and drug intervention services are more difficult to obtain for women, particularly pregnant or parenting women, than for men. The sense of shame and guilt may lead women to try to hide their drug problem from family members or friends. In our society, substance abuse by pregnant or parenting women is often viewed as more deviant than drug or alcohol abuse by those not responsible for small children (Finkelstein, 1994). For this reason, women are more likely than men to encounter opposition to treatment from family and friends (Beckman & Amaro, 1986). As the primary caregiver, women are often encouraged to deny the seriousness of their problem in order to remain with their family. Because programs that allow children into residential treatment are scarce, many women fear they will have to give up custody of their children in order to enter treatment (Finkelstein, 1994). Accessible child care for mothers in treatment has been found to be one of the most important services in improving attendance in drug treatment programs (Nelson-Zlupko, Morrison Dore, Kauffman, & Kaltenbach, 1996). Another problem unique to women is the sexual harassment often present in conventional drug treatment programs. In one study, over half of the participants reported at least one episode of sexual harassment that occurred in a treatment facility (Nelson-Zlupko, et al., 1996). Other common barriers that women face when trying to find treatment include lack of transportation, a safe living environment, and financial resources to pay for their treatment (Laken & Hutchins, 1996). In addition to unique barriers, women have alcoholand drug-related issues that are different from those faced by men. One study that highlights the complexity of problems and needs among pregnant substance-abusing women is the California Perinatal Needs Assessment (PNA; Klein, Crim, & Zahnd, 1997). The 401 pregnant women who completed the PNA questionnaire indicated that many have experienced serious negative personal consequences related to alcohol and drug use, including arrest, homelessness, abuse, and feeling suicidal. It is clear that many forms of violence are common in the lives of women who use alcohol and other drugs. Be-
L. Whiteside-Mansell et al.
cause of the high prevalence of sexual abuse in this population, it is believed that women’s drug use may serve as a way to cope with the feelings that follow traumatic experiences (Boyd, 1993; Wadsworth, Spampneto, & Halbrook, 1995; Wilsnack, Vogeltanz, Klassen, & Harris, 1997). Women with addiction problems also reported unmet needs related to parenting, education, vocational training, health care, and child care (Klein et al., 1997). Unique to women are the issues related to their roles as parents and caregivers. Studies have shown that maternal use of drugs is associated with higher levels of parentrelated stress and child maltreatment (Kelley, 1992). Children of substance users are considered to be at increased risk for physical abuse or neglect. One study of a juvenile court sample showed that parents with documented substance abuse were significantly more likely to have had previous charges of child maltreatment, were more likely to have their children permanently removed from their care, and were more likely to reject court-ordered services (Murphy, et al., 1991). Another study of child abuse and neglect cases showed that parental substance abuse greatly increased the likelihood of re-reports for maltreatment to the child protective service agency (Wolock & Magura, 1996). Alcohol and drug prevention and treatment programs for parenting women must also help their clients cope with problems related to prenatal drug exposure in children. These children may face increased risk of health or developmental problems. There are several medical complications that have been associated with prenatal drug exposure, including, neurological impairment, prematurity, low birth weight, fetal alcohol syndrome, sudden infant death syndrome, intrauterine growth retardation, and central nervous system disorders. Other characteristics that have been associated with drug exposure in children include, irritability, hyperactivity, language delays, poor social skills, motor development delays, and feeding difficulties (Chasnoff & Griffith, 1989; Cunningham, 1992; Tronick & Beeghly, 1992; Zuckerman & Bresnahan, 1991). However, particularly regarding research on cocaine abuse during pregnancy, there has been some difficulty separating the effects of cocaine from those of alcohol, other drug, and cigarette use. Other complicating factors include, poor maternal nutrition, the severity and timing of drug use during pregnancy, and the characteristics of the postnatal environment. Researchers are increasingly acknowledging that postnatal environment is important in contributing to the development outcome of drugexposed infants. Because these infants are at high risk for neglectful parenting, family disruption, poverty, violence, abandonment, and homelessness, the impact of their environment on their development cannot be ignored (Bays, 1990; Coles & Platzman, 1993; Hutchings, 1993; Tronick & Beeghly, 1992; Zuckerman & Bresnahan, 1991).
AOD Program for Women and Children
It is believed that appropriate early intervention services and stable home environments can help mitigate some of the effects of prenatal drug and alcohol exposure (Cunningham, 1992). This idea is supported by the findings of Asher Ornoy, Lukashov, Bar-Hamburger, and Harel (1996), who investigated the role of in utero exposure to heroin and the home environment in the developmental outcomes of children born to heroin-dependent parents. They found that when children born to heroin-dependent mothers were divided into those who were raised at home and those adopted, those raised at home functioned significantly lower, and those adopted functioned similarly to controls. Another adoption study involving drug-exposed children (Barth & Needell, 1996) found that at 4 years after placement with adoptive families, the drug-exposed children functioned similarly to controls on behavior reports, school performance, and health scores. These studies are evidence of the important role that the environment can play in children’s development. This research suggests that a nurturing environment can have a positive impact on drug-exposed children, and offers more evidence as to the appropriateness of comprehensive programs for women and their children. These programs can provide the kind of environment that will be conducive to children’s development. In addition, there is also a need for women to receive services in a timely manner. Chasnoff (as cited in Hawley, Halle, Drasin & Thomas, 1995) has found some evidence concerning the possibility of improved outcome for pregnancies in which the mother ceases cocaine use within the first trimester. All of these findings together point to the importance of women and their children receiving timely and appropriate treatment and intervention services. The few studies of comprehensive women’s treatment programs that are available show that programs offering a wide range of services to women are having some success. Outcome data are available from two residential treatment programs: Amity and Olivia’s House. Amity’s Center for Women and Children (Stevens & Arbiter, 1995) provides long-term therapeutic community treatment for addicted pregnant women and women with children. Preliminary outcome data from the Amity program compare outcomes of treatment dropouts and treatment completers. Treatment completers exhibited better outcomes on alcohol and other drug use, re-arrest, employment, and on the use of support groups (Stevens & Arbiter, 1995). Olivia’s House offers residential and outpatient drug users treatment for mothers and their children (Schumacher, Siegal, Socol, Harkless, & Freeman, 1996). Services offered by Olivia’s House include, case management, crisis intervention, detoxification, residential care, childcare, and outpatient aftercare services. The evaluation of Olivia’s House is ongoing, but preliminary findings indicate that the program is having a positive impact. Comparisons of Addiction Severity Index (McLellan et al., 1992) ratings for treatment completers from intake to discharge reveal reductions in severity for alcohol
267
and drug abuse, psychiatric problems, and family/social problems. In addition, results from the Parenting Stress Index reveal that approximately half of treatment completers experienced significant reductions in parenting stress (Schumacher, et al., 1996). Two nonresidential programs designed to address the needs of pregnant substance-abusing women in a “onestop shopping” model of care are the CHANCES program and the Centers for Addiction and Pregnancy (CAP). The CHANCES program offers coordinated primary care in a single location through a team of nurses, addiction counselors, child-care specialists, a physician, a social worker, and a peer counselor (Tanney & Lowenstein, 1997). Compared to women who entered the program after giving birth, women who received prenatal care through CHANCES had fewer positive toxicologies at delivery, infants with higher birthweights, and more infants born after 36 weeks gestation. In addition, from pretest to posttest, women scored better on four parenting variables: expectations, empathy, corporal punishment, and role reversal (Tanney & Lowenstein, 1997). The CAP program offers women mental health/substance use treatment, obstetric/gynecological care, family planning, pediatrics, transportation, nutritional support, and childcare services (Jansson, Svikis, Lee, Paluzzi, Rutigliano, & Hackerman, 1996). Comparing CAP participants to matched controls, infants of controls were 2.5 times more likely to require neonatal intensive care unit (NICU) admission, and their average length of stay was 6 times longer than infants of treatment participants. In addition, infants of participants were examined using the Bayley Scales of Infant Development at 6, 12, and 24 months and were found to be generally within normal limits of development (Jansson et al., 1996). This study evaluated and examined the evolution of a comprehensive women’s intervention program directed at decreasing maternal substance use and lessening addiction’s harmful effects on pregnancy and postpartum women and their infants. In addition to the detailed examination of the evolution of the program, three empirical research questions were addressed. Although pregnant and parenting women with addiction problems were recruited into the program, this evaluation focused on pregnant entrants and children born during program participation. This focus allowed this study to address the following important questions: (a) Did the intervention result in a sustained decrease in alcohol and other drug use among pregnant women between intake and delivery? (b) Were the birth outcomes improved and obstetric/neonatal complications reduced by program participation? (c) Did women that participated in the program during pregnancy have children with normal growth and development? PROGRAM DESCRIPTION AND EVOLUTION The Arkansas Center for Addictions Research, Education, and Services (AR-CARES) located in Little Rock is
268
a licensed facility that (a) provides residential and outpatient substance abuse prevention and treatment services to low-income pregnant and parenting women and their children, and (b) provides leadership to improve and change the system of care for addicted mothers and their families. AR-CARES was established as a 5-year Center for Substance Abuse Prevention (CSAP) PPWI demonstration project. The goals of this 5-year project were to improve the growth and development of the children of clients served, support the client in recovery from substance abuse, and to develop the structure to provide and expand a quality program after initial funding ended.
The Planned Program The model prevention and treatment program was initially planned as a 4 and 1/2 hours per day, 5 days per week, intensive outpatient program based on Miller’s self-in-relation theory as adapted by Finkelstein (1996) through her work with addicted mothers at the Center for Addiction, Pregnancy, and Parenting in Cambridge, MA. This model emphasizes the importance of relationships in the lives of pregnant and parenting women and the need to include relational issues in the treatment program. As a part of their treatment, women need to learn to participate in satisfying and supportive relationships. Table 1 lists the services available at the beginning to the program. The intensive phase of the program was designed to last for at least 12 weeks and serve 9 to 12 women at any one time. The clinical facility was administratively located within the Department of Obstetrics and Gynecology at the state’s only medical university and it was expected that this would be the source of the majority of client referrals. It was physically located in a tree-lined, off-campus facility in a stable, racially mixed neighborhood. As much as possible, the program was to be a “onestop shopping” model implemented by a multidisciplinary team and guided by an individualized treatment plan. On-site services planned, in addition to education and counseling, included 24-hour on-call clinical staff, prenatal care, and Women, Infants, and Children (WIC) services. It was planned that referrals would be made as needed for hospitalization, specialized services for program infants/children, and for birth-related hospitalizations. The plan for clinical services delivery included a team approach, using a master’s-level social worker, master’slevel nurse practitioner, case managers, and consultants in medicine (obstetrics, pediatrics, psychiatry), addictions, psychology, and law/ethics. The project director was to serve as team leader. Biweekly group sessions were to be held with the mother’s family of choice regarding recovery issues for pregnant and parenting women and focusing on issues ranging from communication skills to the 12-step recovery program (Table 1).
L. Whiteside-Mansell et al. TABLE 1 Initial Services of Outpatient Program for Women and Children
4–5 hour treatment day Assistance in locating child care in the community, as needed Alcohol and drug use assessment Education and treatment Mental health assessment and referral Life skills assessment and development Group and individual counseling, covering the following areas: Denial The disease process of addiction Physiology and pharmacology of tobacco, alcohol, and other drugs Effect of tobacco, alcohol, and other drugs on the mother and fetus Maternal–fetal/infant bonding Parenting the drug-exposed infant Women in relationships Women’s issues in recovery Loss and grief Anger and blame Family dynamics in recovery 12-step recovery Self-esteem building Relapse prevention AIDS and other sexually transmitted diseases Preterm-birth prevention Preparation for labor and delivery Family planning Child development and care Parenting education and support Health services, including: Prenatal care Delivery services Postpartum and interconceptional care Child health services Health education, including: Prenatal Infant health and development Nutrition Child safety Labor and delivery Family planning Prevention of sexually transmitted disease Service coordination
Barriers Although a preliminary study had shown a clear need for a treatment program in the community, the number of initial participants was about half of the number expected. Input from clients, staff, and applicants resulted in the identification of three primary barriers: lack of child care, lack of transportation, and lack of safe, drugfree housing. The project had planned to place infants in existing child-care centers, but found no funding for child-care existed. In addition, child-care regulations prevented the entry of an infant under 6 weeks old into a licensed childcare facility. Transportation was to be provided by the
AOD Program for Women and Children
Red Cross Wheels Program; however, a local transit contract prohibited Red Cross from contracting with us. Housing was a particular problem. The one homeless shelter that accepted children required women to attend their program even though it did not include drug abuse treatment. Many clients were living in housing that was temporary, unstable, or that included other residents who did not support the client seeking treatment. In short, the target population of women did not have the social supports required to attend a structured 4–5-hour per day outpatient program.
Program Service Changes Because there was both administrative and staff support to develop a program that met client needs, services were dynamic throughout the project, with additional funding sought to provide additional services. Over the course of the project, on-campus residential support services were obtained to house 13 families at one time. The majority of women entering the program elected residential support services. The average stay in the intensive phase was 15 weeks. However, many families (60%) left by the end of 4 weeks, while another group (33%) stayed more than 2 months. A few received residential support services for longer than a year. By the end of the project, AR-CARES was advocating more community-based and in-home services, recognizing the need for short-term “crisis” residential support for some families, but also the treatment value of having families in their own homes as quickly as possible. Federal and state welfare reform efforts accented this need to provide community-based services that hastened a mother’s successful employment and independent living. The recent movement away from long-term residential support moves the program closer to its original outpatient design. The addition of residential services allowed the program to address another problem with the initial plan. A need was seen to extend the treatment day to 7 to 8 hours per day. Additional educational sessions included art class, center- and home-based nutrition classes, mother– child play groups, and vocational activities. In response to the failure of the original plans for child care, the program added an on-site infant/toddler nursery program run by a half-time supervisor and volunteer staff. By the end of the fifth year, the children’s program was a licensed facility serving up to 40 children, ranging in age from newborn through 12 years. Open from 7:30 am until 9:00 pm, the child-care center maintains a high staff-to-child ratio and draws on community resources to provide on-site occupational, physical, and speech therapy. To address the transportation problem, a minivan was purchased. Clients with Medicaid were encouraged to access transportation through private Medicaid vendors
269 TABLE 2 Service Additions to Treatment Program by the Fifth Year
7–8 hour treatment day On-site residential support Licensed early intervention services On-site licensed child care Infant and toddler Preschool, school age School age summer program Entrepreneurial skills/vocational education Art classes Community 12-step meeting attendance Cooperative extension services – life skills Off-site residential support Employment skills and counseling Licensed mental health services for client, child, and family On-site evening outpatient treatment/transitional services Transportation Tobacco-free environment
or taxis. The third year of the program another 15 passenger van was added. Table 2 lists additional services offered 5 years after the program began. In addition, existing services changed in content and delivery during the program. For example, based on client and staff report, parent education moved away from didactic parenting education sessions to more mother–child activities. This was also supported by stipends that allowed transitioning clients to work in the on-site child-care center under supervision. Another significant change was seen in the shift from individual treatment plans to individualized family treatment plans. By integrating a mother’s care with that of her child(ren), improved individual and family outcomes were expected. As a result, the state is seeking a Medicaid waiver to cover “family treatment and rehabilitation for addicted women and their children” under an innovative managed-care concept that would pay a capped global family treatment rate. The available health care was expanded with a health clinic that provided prenatal, postpartum, and interconceptional care (Table 2) to mothers participating in the program. Children’s health services included neonatal checkups, child health supervision at an enhanced schedule, and immunizations for target infants. In addition, onsite mental health services and transition services in the evening were made for clients who no longer receive full-day treatment because of school or work commitments. Another change from the initial plan was the source of referrals. Perhaps because of a lack of leadership commitment, referrals did not come as expected from the obstetrics clinic at the medical school. Instead, women were referred to the program from health care, alcohol and drug treatment, child welfare, social services, and criminal justice providers, as well as community-based organizations, family members, and self-referrals.
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METHODS Study Design The ideal design for determining the effects of intervention is an experimental design involving random selection from the population and random assignment of potential participants to intervention and control groups. Such a design was not ethical, nor practical, in part because state regulations require the AR-CARES program to be available to all eligible participants. In an effort to partially compensate for our inability to employ a true experimental design, a quasi-experimental design was used that involves a nonparticipating group. In addition, child growth and development data were collected at multiple points and compared with published normative data. In order to evaluate the effectiveness of the intervention, it is important to examine the degree to which findings converge (from both between- and within-group comparisons) and the degree to which those findings are consistent with expectations. The nonparticipating group included pregnant women who were invited into the study but refused services. The inclusion of this nonparticipating group of women and children in the study allowed an examination of birth outcomes for both women and children and later development for children, as well as an examination of patterns of maternal substance use. While nonparticipating mothers were expected to be similar in some aspects, because differences may exist, data were collected at study intake to compare the two groups on an array of characteristics. Women were interviewed at study intake, the delivery of the target child, and when the target child was 6, 12, and 18 months of age. Delivery data were also obtained by an examination of hospital records. Maternal interviews and child development data were collected in a clinical setting by trained clinical staff. A urine toxicology was obtained at intake and delivery on participating and nonparticipating mothers and infants. For participating women, urine toxicology screens were also obtained several times randomly during the period between study intake and delivery. All infant development data were obtained by a clinician or research assistant meeting standards set by a CSAP national cross-site study. As part of this cross-site study, all data collectors were trained and certified to meet national standards. The Bayley Scales of Infant Development (Bayley, 1969) are designed to provide a basis for the evaluation of a child’s developmental status in the first 2 1/2 years of life. The Mental Scale is designed to assess sensory-perceptual acuities, discriminations, and the ability to respond to these; the early acquisition of “object constancy” and memory, learning, and problem-solving ability; vocalizations and the beginnings of verbal communication; and early evidence of the ability to form generalizations and classifications. Results of the administration of the Mental Scale are expressed as a
standard score, the Mental Development Index (MDI). The Motor Scale is designed to provide a measure of the degree of control of the body, coordination of the large muscles and fine manipulatory skills of the hands and fingers. Results of the administration of the Motor Scale are expressed as a standard score, the Psychomotor Development Index (PDI). The standard scores are normalized to have a mean of 100 and a standard deviation of 15. Sample Description Data concerning current and past alcohol and other drug (AOD) use were obtained from 72 participating women and 23 nonparticipating women at study intake. Delivery assessments were obtained for 27 participating women and 10 nonparticipating women. Table 3 provides demographic information for participating and nonparticipating women. As can be seen by these characteristics, the majority (75%) of participants in this study were African American women in their late to mid-20s who were not married (most had never been married). Although most had not completed high school, about a fourth had completed their general equivalency diploma (GED). Few (3%) were employed when they entered the study, however, most (80%) had worked at a job during the previous 5 years. About one third of the women had legal issues surrounding child protective services (DCFS case open) at the time of intake into the study. Nearly all women reported a history of victimization. Most reported a history of sexual, physical, and emotional abuse. The majority also reported a family history of alcohol and drug use, as well as a previous (or current) partner that used. Many also had a history of prior alcohol or other drug (AOD) treatment. Of the women entering program, 32.4% were required by legal agencies to attend. Women were enrolled an average of 13.6 (SD 5 8.4) weeks before the delivery of their child. Five women enrolled only about 2 weeks before delivery of the target child. The longest time between intake and delivery was 26 weeks. Comparison of Participating and Nonparticipating Women Participating and nonparticipating women were compared on a variety of characteristics and initial status variables. Participating and nonparticipating women appear to be similar in most ways in demographic characteristics and resources. The two groups of women did not differ in the amount, type, or consequences of AOD use at intake. No differences were found between participating and nonparticipating women in their reported history of coresidency with AOD users, victimization, or legal involvement. No differences were seen between the two groups in their self-reported barriers to accessing care.
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TABLE 3 Initial Demographic Description of Participating and Nonparticipating Women as Percent or Mean
Characteristic
Average age (years) Marital status Married Never married Race (African American) GED complete Average level of education (years) Average income per month Current AOD use by partner Current DCFS case open History of victim of abuse Rape Incest Physical abuse Childhood abuse Emotional abuse History of arrested History of treatment Residential treatment History of family AOD Week of pregnancy at intake Average number of previous births
Participating Women (n 5 72)
Nonparticipating Women (n 5 23)
M 5 28.8, SD 5 5.2
M 5 26.3, SD 5 5.2
11.6% 60.9% 75% 20.0% M 5 11.1, SD 5 1.7 M 5 $268.0, SD 5 $279 65.5% 31.4%
17.4% 60.9% 70% 23.8% M 5 11.6, SD 5 1.9 M 5 $192.0, SD 5 $309 68.8% 11.8%
40.6% 21.9% 71.9% 30.3% 72.7% 71.4%
63.2% 42.1% 75.0% 31.6% 78.9% 85.7%
60.0% 80.0% M 5 24.2, SD 5 10.4
42.8% 90.0% M 5 23.8, SD 5 10.9
M 5 2.8, SD 5 2.2
M 5 1.6, SD 5 1.3
AOD 5 Alcohol or other drugs; DCFS 5 Department of Child and Family Services; GED 5 General Equivalency Diploma.
RESULTS Examination of AOD Use Table 4 shows the percent of women that reported the use of substances at intake, and delivery assessments. At intake, most clients reported the use of alcohol or other substance use. For example, 85% reported the use of marijuana, 40% the use of cocaine, 90% the use of crack, and 15% reported the use of amphetamines. By the time of the birth of their child, the numbers of participating women and nonparticipating women reporting the use of alcohol dropped significantly, based on paired t-tests. As seen in Table 4, 83.6% of participating women reported alcohol use at intake and only 4% reported any use between intake and delivery. This is a significant reduction in the proportion of alcohol users among participating women (t 5 29.3, p 5 .001). The drop in the number of nonparticipating women (90.5% to 33%), while statistically significant (t 5 24.6, p 5 .003), was not as dramatic. Although the number of both participating and nonparticipating women reporting continued alcohol use declined, the number of participating women reporting alcohol use declined significantly more than nonparticipating women (x2 5 5.4 p 5 .02). Among the women that reported drinking alcohol during the last 3 months, no differences were found between participating and nonparticipating women, with both reporting about 3 drinks a day.
At the time of the birth of their child, the number of participating and nonparticipating women reporting other drug use dropped significantly, based on paired t-tests. At intake, 91.7% of pregnant participating women reported other drug use; at delivery only 3.7% reported continued drug use. This is a significant reduction in the proportion of substance use among participating women (t 5 225.0 p 5 .001). Of the 95.7% of nonparticipating women reporting other drug use at intake, significantly fewer (33.3%) reported continued use at delivery (t 5 TABLE 4 Percent of Participating and Nonparticipating Women Reporting Alcohol, Other Drug, and Tobacco Use
Substance
Alcohol Intake Delivery Other drug use Intake Delivery Tobacco Intake Delivery
% Participating Women (n 5 72)
% Nonparticipating Women (n 5 23)
83.6 4.0*,**
90.5 33.3*,**
91.7 3.7*,**
95.7 33.3*,**
67.0 55.6**
88.0 90.0**
* p , .05 between intake and delivery assessments. ** p , .05 between participating and nonparticipating.
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L. Whiteside-Mansell et al. TABLE 5 Number and Percent of Women Experiencing Obstetric/Neonatal Complications by Participating and Nonparticipating Women
Participating Complications
Total reporting Any type of complication Placental abruption Maternal infection Premature labor Preeclampsia Fetal distress Meconium-stained amniotic fluid Other
Nonparticipating
n
%
n
%
27 12 1 3* 2* 1 2 6 4
46 4 11 7 4 7 23 15
10 4 0 4* 4* 0 0 1 1
40 0 40 40 0 0 10 10
* p , .05.
23.4, p 5 .01). Similar to the reports of alcohol use, participating women reported significantly less use of other substances than nonparticipating women at delivery (x2 5 5.3, p 5 .02). The results of urine toxicology analyses appear to support the self-report of women concerning their use of substances. Twenty-five participating women received a total of 135 urine screens during the period between study intake and delivery—an average of 4.9 screens each. Of these only two were positive. Infants also received urine screens at birth. Of the 21 infants of participating women assessed, 1 had a positive urine test, 2 of the 9 nonparticipating infants were positive. The number of participating women reporting tobacco use at delivery was significantly less than the number reporting tobacco use at intake (p 5 .01). This was not true for nonparticipating women. All six of the nonparticipating women who reported tobacco use at intake continued its use at delivery. Significantly more nonparticipating women reported smoking at the time of delivery than participating women (p 5 .05). When the number of cigarettes smoked a day are examined, participating women reported smoking significantly fewer cigarettes than nonparticipating women (p 5 .02). For example, when all women in both groups are considered, participating women report smoking 3.4 (SD 5 4.3) cigarettes a day and nonparticipating women report 8.1 (SD 5 6.5) cigarettes a day. Among the women in each group who reported smoking (excluding women that do not smoke), the difference in the number approaches significance (p 5 .096). For this subgroup of women who smoked, participating women smoked an average of 6.8 cigarettes (SD 5 3.6) per day and nonparticipating women smoked an average of 10.4 (SD 5 5.4). Birth Outcomes The data suggest that program participation may have resulted in fewer complications of specific types of birth. Outcome data were examined in independent t-tests between
participating and nonparticipating women. In addition, ordinary least squares linear regression was used to examine the impact of the length of participation on outcome measures. For these analyses, nonparticipating women were considered to have zero length of participation. As can be seen in Table 5, the rate of complications was similar (about 40–46%) for participating (n 5 12) and nonparticipating (n 5 4) women. However, significantly fewer participating women experienced premature labor (p 5 .02) and maternal infection (p 5 .05) than nonparticipating women. No differences were seen when the length of participation was examined. As shown in Table 6, participating mothers stayed in the hospital an average of 2.3 days after the birth of the target child compared to an average of 5 days for nonparticipating mothers (t 5 22.2, p 5 .03). These analyses included one nonparticipating women with an exceptionally long hospital stay of 21 days. When this subject is excluded from the analyses, the length of stay is no longer statistically different. The number of infant hospital days after the delivery is not different for children of participating and nonparticipating women. No statistically significant differences were found between infants of participating and nonparticipating women in the incidence (11% and 40%, respectively) or duration of neonatal intensive care unit (NICU) treatment (.44 and .88 days, respectively). No differences were seen when the length of participation was examined. Infant birthweight was similar for each group when compared with independent t-tests. However, when length of time between program intake and the birth of the child is taken into account, longer program participation is associated with larger birthweight (F 5 5.08, p 5 .03, explaining 13% of the variance). No statistical differences were found in the length of the infants in each group. Although the difference did not reach the .05 significance level, infants of participating women tended to have larger head circumferences (35 cm as compared with 33 cm; t 5 21.9, p 5 .07). One-minute and 5-minute Apgar scores were similar for both groups of infants. The
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TABLE 6 Maternal and Infant Health Markers at Delivery by Participating and Nonparticipating Women
Participating Delivery Information
Number of maternal hospital daysa Number of infant hospital daysb Number of days in NICUc Infant weight Infant length (inches) Infant head circumference (centimeters) 1-minute Apgar score 5-minute Apgar score Weeks of gestation at delivery
Nonparticipating
M
SD
M
SD
2.3* 3.1 .4 6.5* 18.7 35** 8 8 38*
1.2 2.0 1.4 1.4 2.1 3.6 1.6 1.6 2.7
5* 4 .8 5.8* 19.8 33** 8 9 36*
5.9 4.0 2.2 1.1 .8 .7 1.8 .5 2.6
NICU 5 neonatal intensive care unit. a Includes one nonparticipating woman with a 21-day hospital stay. Excluding this extreme observation, nonparticipating women had a mean hospital stay of 3 days. b Includes an infant of a nonparticipating woman with a 14-day hospital stay. With that infant excluded the mean is 3. c Three infants of participating women and two infants of a nonparticipating woman had NICU days. Of these five, the mean NICU stay was 4 days for other groups. * p , .05. ** p , .10.
gestational age of infants of participating women was 2 weeks more than infants of nonparticipating women. This was found both in the t-test analysis (t 5 2.2, p 5 .03) and the examination of length of participation analysis (F 5 5.27, p 5 .03).
At 6 months of age, development measures for all children assessed were within normal ranges. Although one child of a participating mother scored in the 5th percentile for growth at 6 months, on average, children of both participating and nonparticipating women were in normal ranges. Too few children of nonparticipating clients were assessed at 6 months to perform reliable statistical tests. At 12 months of age, all of the children of participating women still scored in the normal range for cognitive development, however, one child of a nonparticipating
Child Growth and Development Table 7 shows growth and development markers for children of both participating and nonparticipating women.
TABLE 7 Mean, Minimum, and Maximum Growth and Development Scores by Participating and Nonparticipating Groups
Participating Assessment Time
6 Month Bayley MDI Bayley PDI Weight percentile Length percentile Head circumference percentile 12 Month Bayley MDI Bayley PDI Weight percentile Length percentile Head circumference percentile 18 Month Bayley MDI Bayley PDI Weight percentile Length percentile Head circumference percentile
Nonparticipating
Number of Children
Average
Minimum/Maximum
Number of Children
Average
Minimum/Maximum
16 16 7 7 7
99.38 98.38 36.43 36.43 47.14
92/107 72/114 5/75 5/75 5/75
3 3 2 2 2
100.00 102.00 17.50 17.50 17.50
94/104 100/104 10/25 10/25 10/25
9 9 5 5 5
98.22 101.11 50.00 55.00 55.00
84/127 89/109 25/100 25/75 25/100
5 5 3 2 2
89.80 95.00 11.67 10.00 15.00
69/102 79/113 5/20 10/10 5/25
6 6 2 2 2
91.71 97.50 25.00 37.50 37.50
79/103 82/107 25/25 25/50 25/50
1 1 1 1 1
79.00 79.00 10.00 10.00 5.00
79/79 79/79 10/10 10/10 5/5
MDI 5 Mental Development Index; PDI 5 Psychomotor Development Index.
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woman scored below the normal range for both PDI (79) and MID (69) Bayley subscales. Independent t-tests were used to compare the cognitive scores for children of participating and nonparticipating women. There were no statistical differences between the two groups on cognitive development scores. Growth measures for children of participating women indicate that these children are within normal ranges, however, none of the three children of nonparticipating women showed growth markers above the 25 percentile. These differences could not be reliability tested because of the low number of assessments obtained for children of nonparticipating women. At 18 months of age, a similar pattern continued in the cognitive development, as was seen at 12 months of age. It was not possible to perform statistical tests of scores because only one child of a nonparticipating woman was assessed and only two participating children were assessed for growth. However, it can be noted that all of the children of participating women were within normal ranges for both growth and development.
DISCUSSION This study examined the evolution of the AR-CARES over a 5-year period and evaluated it’s impact on women and children. The program changed significantly over this time, based upon input from clients and staff, and in response to changing community resources. Program participants and staff saw the program’s ability to remain flexible enough to respond to emerging opportunities to better serve the target population as a strength. This flexibility allowed the addition of services such as residential facilities, mental health counseling, child care, early intervention for children, and transportation. Although the program was effective in influencing maternal health and social outcomes, this study only examined maternal AOD use, pregnancy outcomes, early infant health, and infant development status. An examination of the outcomes for women and children who participated in the program compared to women and children that did not suggests that the program had a positive impact. The reduction of AOD use was associated with improvements in birth outcomes and living environments for infants of participating mothers. Program participation was associated with a significant reduction in substance use during the time before the birth of the target child. Participating women had a lower incidence of premature labor and maternal infections. Infants of women that participated in the program had higher gestational ages. When the length of participation was considered, infants of women that participated had significantly higher birthweights than infants of nonparticipating women. Birthweight and gestational age are key indicators of later health. In particular, low birthweight infants are at a greater risk for death and long-term health and developmental disabilities than normal birthweight infants.
On average, nonparticipating women also had longer maternal hospital stays after delivery. Although this finding is driven by the stay of one nonparticipating woman, this is the exception that the program is intended to prevent. Although there were not statistical differences found between the number of infant hospital days of NICU days, this is in part due to a lack of power to detect differences. Infants of participating women tended to have shorter hospital days. There are also indications that the program may have had an impact on later child development. Children of women who participated in the program had normal growth and cognitive development on standardized measures. Because there were very few follow-up assessments made with nonparticipating children, it was not possible to meaningfully compare growth and development between children of participating and nonparticipating women. However, as would be expected, some children of nonparticipating women were not in the normal ranges for growth and development. Because all children were prenatally exposed to substances, there is some support for the hypotheses that the impact of the early home environment and parenting may be protective for many children. Three important factors may have prevented this study from showing more conclusive results. First, the length of this study did not allow for a later follow-up. It is possible that the impact of the program may be strongest in the behavioral development of children in more formal settings like kindergarten. Second, the number of follow-up assessments were small and provided limited power for statistical analysis. However, the findings converge (birth outcomes and later development) and are consistent with expectations. In addition, even where statistical significance was not found the trend of the results are consistent with other findings that were statistically significant. Finally, there were large variations in the amount of participation by women. Women that entered the program only 2 weeks before the birth of their child were included with women that enrolled 26 weeks before delivery. However, the results of this study suggest that longer participation may result in more positive birth outcomes. For example, the length of participation was predictive of birthweight and gestational age. Although the program staff made efforts to recruit women early in their pregnancy, because the program was new and many links with other agencies had to be established, they were not always successful. Because the statistical tests employed in this study assume an experimental design, the lack of randomization in this study is also a limitation. However, this problem is alleviated to some degree by the finding that women who participated and women who did not were similar on a wide variety of characteristics. It is possible that the groups were different on some characteristic not measured. However, these differences may have impacted the result in either positive or negative ways. For exam-
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ple, it is possible that participating women were more motivated than nonparticipating women. On the other hand, it is likely that the nonparticipating women available for assessment were the most stable of this group and perhaps the women most likely to have positive outcomes. It is important to note that in spite of the lack of power associated with small samples and other limitations that might lead to a lack of findings, positive differences were found. This is due, in part, to the dynamic process this program used to respond to client needs and changing community resources. Leanne Whiteside-Mansell, EdD* Cynthia C. Crone, MNSc† and Nicola A. Conners, MEd‡ *University of Arkansas at Little Rock, Little Rock, AR †University of Arkansas for Medical Sciences, Little Rock, AR ‡University of Memphis, Memphis, TN REFERENCES Asher Ornoy, V.M., Lukashov, I., Bar-Hamburger, R., & Harel, S. (1996). The developmental outcome of children born to heroindependent mother, raised at home or adopted. Child Abuse and Neglect, 20, 385–396. Barth, R.P., & Needell, B. (1996). Outcomes for drug-exposed children four years post-adoption. Children and Youth Services Review, 18, 37–56. Bayley, N. (1969). Bayley Scales of Infant Development. New York: Psychological Corporation. Bays, J. (1990). Substance abuse and child abuse. Pediatric Clinics of North America, 37, 881–903. Beckman, L.J., & Amaro, H. (1986). Personal and social difficulties faced by women and men entering alcoholism treatment. Journal of Studies on Alcohol, 47, 135–145. Boyd, C.J. (1993). The antecedents of women’s crack cocaine abuse: Family substance abuse, sexual abuse, depression and illicit drug use. Journal of Substance Abuse Treatment, 10, 433–438. Center for Substance Abuse Treatment. (1994). Practical approaches in the treatment of women who abuse alcohol and other drugs. (DHHS No. 94-3006). Washington, DC: U.S. Government Printing Office. Chasnoff, I.J., & Griffith, D.R. (1989). Cocaine: Clinical studies of pregnancy and the newborn. Annals of the New York Academy of Sciences, 562, 260–266. Coles, C.D., & Platzman, K.A. (1993). Behavioral development in children prenatally exposed to drugs and alcohol. The International Journal of the Addictions, 28, 1393–1433. Cunningham, R. (1992). Developmentally appropriate psychosocial care for children affected by parental chemical dependence. Journal of Health Care for the Poor and Underserved, 3, 208–221. Finkelstein, N. (1994). Treatment issues for alcohol- and drug-dependent pregnant and parenting women. Health and Social Work, 19, 7–15. Finkelstein, N. (1996). Using the relational model as a context for treating pregnant and parenting chemically dependent women. Journal of Chemical Dependency Treatment, 6, 23–44.
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