For many parents who misuse substances their current problems can be traced to adverse childhood experiences, including their own chaotic family of origin. With this adversity in early life they are often left psychologically damaged and poorly prepared to provide a safe, stable and nurturing family environment for their own children. The need to engage in criminal activities when the substance of abuse is an illicit drug makes change for these families very difficult (see Dawe et al., 2007 for an extensive review of this literature).
Sadly, for children raised in families with parental substance abuse, the risk of child maltreatment and particularly child neglect, is substantially higher than in families without substance abuse (National Center on Addiction and Substance Abuse, 1999; Walsh et al., 2003). Substance use disorder in a parent has been identified as the strongest predictor of subsequent new cases of child abuse and neglect 12 months later (Chaffin et al., 1996). U.S. estimates indicate that approximately 60 percent of families that come to the attention of the child welfare system also have substance abuse issues (Chaffin et al., 1996).
It is difficult to determine just how many children are at risk of adverse outcomes as a result of living in families with parental substance abuse. One large scale U.S. survey reported that approximately 6.1 million (nine percent) children under the age of 18 were living with at least one parent who met criteria for alcohol or substance abuse in the previous year. This number included more than 500,000 children who lived with a parent who abused or was dependent on alcohol and an illicit drug (Office of Applied Studies, 2003). In Australia, recent estimates suggest that approximately 13 percent of Australian children are living in a family where binge drinking and/or other illicit drug use occur regularly (Dawe et al., 2007). In the United Kingdom, the number of children under the age of 16 living with a parent who used illicit drugs was estimated at two to three percent of children in England and four to six percent of children in Scotland.
The scale of the problem is large and intervening to change the trajectory for children living in multiproblem families is not straightforward. We have argued that an intervention will need to focus on many different aspects of families’ lives. Thus, an effective treatment requires an ecological perspective that incorporates interventions to: improve the child’s behavior across different settings such as home and school; improve parental functioning that, at a minimum, requires stabilization or reduction in substance use and an improvement in parental mental health; a significant shift from an often punitive and authoritarian parenting style to a more nurturing and loving parenting style, balanced by consistent household rules and routines; and increasing the families’ social connectedness and social capital.
Currently, most drug treatment services focus only on the presenting client, and make no attempt to extend treatment to include the family. This is understandable, given the resources and time required to expand services to become more family-focused. However, it is almost certainly the case that shifting from an adult client focus to a family focus will help break the intergenerational pattern of problems (e.g., Brooks et al., 2002). Indeed, rates of child abuse potential do not appear to be influenced by participation in drug treatment alone, with approximately one-third of mothers in treatment scoring in the clinical range for child abuse potential (Hogan et al., 2006).
The Parents Under Pressure (PUP) program is an intervention specifically designed for use with multi-problem families, where children are at risk of adverse outcomes. The program was developed to target families where there is parental substance abuse and/or child protection concerns. While it is unrealistic to expect a single intervention to provide for all of a family’s needs, we suggest that with multi-problem families, having as few agencies as possible delivering a comprehensive intervention is better than having many specialist agencies offering interventions for particular aspects of a family’s life. In practice, this means that a treatment program should aim to reduce parental mood and anxiety problems; enhance parenting skills; address child behavior problems; and address real world issues, such as housing, employment and adult education. The program needs to be flexible, and able to accommodate the many crises that invariably arise during treatment. It should be home-based to help families engage in the treatment; but it also needs to be sufficiently structured so the therapist and family are working towards a set of shared goals. The PUP program is a structured but non-sequential intervention, consisting of 10 modules, each addressing a different domain of the family ecology (Harnett, Dawe & Rendalls, 2005). An assessment of each family determines which modules are used, to what extent and in which order. The overriding aim of the PUP program is to help provide a safe and nurturing family environment conducive to positive outcomes for the children.
Program description
The first two modules of the PUP program include procedures for conducting an assessment of the family and identifying and defining therapeutic goals. The third module challenges a pervasive negative view of self by helping the parent find evidence of his or her own parental competency. Many parents come to the PUP program believing that they are failed or hopeless parents, a view further reinforced by external sources such as media and social services. While there are many times when a parent has failed in his or her role, for someone to hold the belief that she is a “bad mom” allows for little confidence or parental self efficacy and will prevent her from acknowledging her own strengths, and often as a corollary of this, her children’s strengths.
The aim of the fourth module is to teach and encourage the use of emotional regulation, positive thinking and self-soothing skills. While there is a focus on the parent(s) we encourage parents to practice these skills with their children. Modules five and six focus on child management skills and child centered parenting (e.g., play, praise). These techniques are taught within a mindfulness perspective. Specifically, parents are encouraged to use mindful awareness of their own emotional state to allow for a more authentic engagement with their child during play, and to help enforce rules in a calm and authorative manner. Module seven includes relapse prevention techniques for problematic substance use. The remaining three modules focus on extending social supports, life skills and relationship problems.
In addition to the techniques described in the modules, there are process issues that are equally as important. The program identifies and clearly defines goals to be met over the course of therapy. This is important for a number if reasons. First, a major difficulty in working with multi-problem families is regularly occurring crises that have the potential to hijack the progress of therapy. Programs that involve a structured and inflexible sequence of sessions become derailed when a crisis takes precedence over the intended content of that session. The PUP program anticipates and has procedures to explicitly handle these crises. In fact, the crises are viewed as therapeutic opportunities to help families deal with issues that arise, so they can refocus and achieve set goals. We acknowledge that many crises that arise cannot be easily solved, yet the parents faced with these crises still have to provide meals; get the children to school; set limits and enforce them fairly and consistently; and be emotionally available and sensitive to their needs – tasks that are very difficult in stressful circumstances. Under these circumstances, a repertoire of parenting skills and problem solving skills are important, but not sufficient, to be an effective parent. We have argued that it also is necessary to help parents learn skills to regulate their emotions while under stress. Emotional reactivity limits the parents’ ability to be emotionally available to the child, and can result in overly harsh and inconsistent child management. Thus, the content of module four is intervention throughout the program irrespective of session topic or content.
Another reason goal setting is important, is that it facilitates a conceptual understanding of parents’ difficulties in the parenting role. Specifically, we encourage parents to identify hindrances to achieving therapeutic goals. The PUP philosophy is that there is no single “deficit” to explain parenting problems. Rather, hindrances can occur across ecological domains. Some children are more temperamentally difficult than others, and some parents have less support than others. Thus, we consciously avoid a parenting deficit model and help parents to acknowledge the many influences that make parenting difficult. We find this approach is less likely to undermine parents’ confidence and helps them to acknowledge the importance of making changes in various areas of their life.
Goal setting also is vital, as parents need to experience the success of achievement. In order for this to occur, parents must have exerted effort and persevered in their efforts. This provides an important opportunity for therapists to acknowledge the parents’ success. We find this is particularly powerful when parents have been invited to identify the goals of therapy. Thus, the process of identifying and defining goals is, in itself, important. In the PUP program we ask parents what they hope for their children in adulthood: good health, friends, self-confidence, law abiding, employment, cultural connection, etc. This type of goal identification can lead to implementation of parenting practices that are consistent with these values, and can help set goals. For example, if a parent wants his or her child to be self-confident, then praising the child and acknowledging his or her achievements is important. This, in turn, can help build parental self efficacy as the parent begins to notice the good behaviour instead of focusing on unacceptable behavior.
Effectiveness of PUP
We have undertaken a series of single case studies (Dawe, Harnett & Rendalls, 2003; Harnett & Dawe, submitted) and conducted one randomized controlled trial of the PUP program (Dawe & Harnett, 2007). We are interested in changes at a group level, but also importantly, at an individual family level, so all of our studies include an analysis based on the reliable change index (Jacobson & Truax, 1991). This index determines whether there has been a clinically significant improvement or deterioration between baseline assessment and at follow-up.
In both single case studies, we demonstrate that substantial improvements were found across a number of areas including: child abuse potential; parental stress; and child behavior. It is important, however, to emphasize that not all families showed such improvement. In our first series — which included families who were on methadone maintenance — six out of eight families showed a reliable reduction in child abuse potential (Dawe et al., 2003). In a sample of 12 families referred from child protection, eight showed significant reductions in at least one domain (Harnett & Dawe, submitted). Encouraging results were obtained in the randomized controlled trial, in which PUP was compared to a brief intervention, and treatment as usual (which consisted of the standard treatment provided by the methadone clinics, including prescription of methadone and some case management, such as helping with accommodations and social security) in families with a parent on methadone maintenance (Dawe & Harnett, 2007).
For the group of families receiving PUP, there were significant reductions in: child abuse potential, parenting stress and child behavior. More than one-third of families in the PUP group reported a reduction that met the strict criteria for change. Importantly, more than one-third of families in the treatment as usual group showed an increase in child abuse potential that also met criteria for a reliable change. Thus, while the PUP program holds great promise, it is important to bear in mind that making significant and enduring changes in multi-problem families is difficult, and that for some families, such changes are not possible.
A PUP case illustration
A family was referred to the PUP program by the drug treatment service that provided opioid substitution, as they had recently been required to notify the family to local child protection services because of:
1) The mother’s increasing use of alcohol, as well as her prescribed methadone maintenance; and
2) One child in primary school was not attending school.
Because of her substance use and her inability to get her child to school, the child protection service had concerns about her ability to care for her children. 
Family background: The family consisted of Alice, a 30-year-old single mother; and two children, eight-year-old Julie and six-year-old Rebecca. Alice had become dependent on heroin shortly after Rebecca’s birth, but had sought treatment and been on methadone maintenance for four years. She had been introduced to heroin by her boyfriend (also Rebecca’s father) as a way of managing her feelings, following a difficult birth.
Alice had a difficult life, coming from a family with parental alcohol abuse and domestic violence, and living in a deprived neighborhood. Despite many adversities she completed high school and had been employed in a clerical position at a large supermarket chain. She remained in this job for several years until meeting Julie’s father. This started a period of disruption — they relocated and both became unemployed. Already a bit of a drinker, Alice’s alcohol consumption increased as the relationship became more unstable. Alice was able to quit drinking after becoming pregnant. However, the relationship continued to deteriorate, and before Julie’s first birthday, Alice left the father and relocated. She then met her current boyfriend, and became pregnant with Rebecca. While they do not live together, they see one another often, but the relationship is problematic. The boyfriend continues to use heroin, despite being on the methadone program. Further, in recent months, the arguments have escalated, and he has hit Alice on several occasions. Although remorseful afterwards, Alice is aware that the violence is increasing and that the girls are becoming more withdrawn and anxious when the boyfriend is around.
The children: The identified target child was six-year-old Rebecca. Alice reported that Rebecca had always been a shy child — unwilling to leave her mother’s side and very unadventurous as a small girl. Rebecca attended kindergarten at age four, and began formal school at age five. She appeared to settle into school initially. Recently, however, Alice has found it increasingly difficult to get Rebecca to school, escalating to the point where Rebecca refused to enter the schoolyard.
Assessment: An initial assessment that included objective measures of both mother’s and child’s functioning revealed the following:
Alice was drinking almost daily, with a maximum alcohol intake of seven standard drinks. She was not alcohol-dependent, but met diagnostic criteria for alcohol abuse. She was stable on 70mg methadone and was not using other illicit drugs. She scored in the clinical range on measures of anxiety and stress, and she reported that she believed that she was a hopeless mother who had “made her children’s lives a mess.”
Both children had elevated scores on measures of child anxiety, completed by both Alice, and independently by the schoolteacher. Rebecca was reported to display particularly high levels of anxiety. Both girls had scores in the non-clinical range on measures of externalizing behaviors.
Goals for intervention: In the assessment feedback session, Alice showed a clear understanding of the problems, and goals were established for the intervention. These goals were to assist the mother in using strategies (other than alcohol) to help cope with stress, and for Rebecca, to attend school on a regular basis.
PUP in practice: The intervention for Alice began with helping her control her alcohol use. Since anxiety and stress precipitated the drinking, the initial focus was on developing affect regulation skills. Alice was encouraged to allocate time for relaxation, and she was taught a number of relaxation strategies, including diaphragmatic breathing. Alice was encouraged to reinstitute, on a regular basis, her previously preferred method of relaxation, a warm bath with relaxing aromas. In order to accomplish this, it was necessary to engage in problem solving to ensure her two children were being looked after while she spent time caring for herself.
Alice was also taught mindful breathing practice as a means of regulating her affect. Specifically, she was instructed to focus attention on the physical sensation of the breathing process — the feel of the breath passing through her nostrils, and the rise and fall of her abdomen on the in and out breaths. While doing this, Alice was encouraged to let go of thoughts passing through her mind, and to accept whatever feelings happen to arise while practicing the mindful breathing. This technique aimed to help her develop a greater awareness of the influence of worries and concerns on her emotional well-being, and a technique for calming down by letting go of these worries.
Alice strongly believed that she was a bad mother. An important focus of therapy was to help her acknowledge her many strengths. A videotape was made of her interacting with Rebecca. In the subsequent session she was shown segments of the video that showed a lot of warmth while playing with her daughter. That she could be responsive and emotionally available in her interactions with her daughter was something that she took pride in acknowledging. This helped Alice begin to challenge her belief that she was a poor mother. In addition, Alice was encouraged to schedule special time with each of the girls for child-centred play. She was encouraged to notice and praise her daughters when they were compliant and well-behaved. Her daughters become more responsive to her which, in turn, made her feel closer to them.
It became clear that Rebecca was experiencing considerable anxiety symptoms, which in turn, was driving her refusal to attend school. At the outset, Alice perceived the school to be unhelpful in supporting her efforts to get her daughter back to school. However, she admitted she had not formally met with the school to explain the situation. Together with the PUP therapist, Alice developed an action plan that included steps to approach the school and negotiate their involvement and support in developing a plan for getting Rebecca back to school. Alice set up a meeting with the school principal and class teacher that the PUP therapist agreed to attend to support her. Successfully setting up the meeting was an important achievement for Alice, who previously been reluctant to contact the school due to concerns that they may learn she was on methadone. At the meeting, the school representatives suggested that Rebecca might attend “before school activities” to experience a positive aspect of the school. Initially, Alice escorted Rebecca and stayed while Rebecca participated in these activities. Over the next few weeks, the school provided an increasing number of out-of-classroom activities, with the aim of gradually introducing Rebecca back into a normal classroom routine. During this time, the PUP therapist spent time with Alice supporting her attempts to help Rebecca get to school. Interventions included: getting Alice to teach her girls diaphragmatic breathing to help the children manage their anxiety, “breathing deeply and allowing the butterflies to gently fly away”; and helping the girls identify times when they were “being brave” and were successful in “doing some scary things.”
After several sessions Alice felt there was sufficient trust in the therapeutic relationship to tell the PUP therapist that the relationship with her partner was more violent that she has indicated in the assessment. Options were considered that were in the best interests of both Alice and the children. Alice acknowledged that the violence the girls were witnessing was a major source of anxiety and could not continue. The PUP therapist encouraged Alice to develop an action plan to deal with this issue. Alice, found she was eligible to receive free legal advice from a women’s legal service. From this, she was informed how to take out a domestic violence order to prevent her partner from visiting.
A final area that was targeted for intervention was Alice’s social isolation. In order to reduce her isolation from the community, Alice was encouraged to find activities outside the family. To begin with, she was encouraged to become involved in the school by offering to help out in the school canteen, and as a volunteer supervisor on school outings with the children. In doing this she met another mother who lived nearby. This developed into a friendship and she began going out socially on a regular basis, once or twice a week. 
Process issues: Alice was initially guarded in her response to help. However, several factors were significant in reducing her defensiveness. First, she admitted to being under stress and unsupported, but had not seen this as relevant to her parenting. Considering that these factors directly interfere with any parents’ ability to care for their child and that she wasn’t in any absolute sense a “bad parent” reduced her defensiveness. Second, the goals of therapy were clear and relevant, having been mutually negotiated. Finally, emphasizing that there were many positive aspects in this mother’s life, despite Rebecca’s school refusal and Alice’s alcohol abuse, contributed to the development of a strong and trusting relationship between Alice and her therapist.
Outcome: Alice was drinking less by the end of treatment. Rebecca was attending school on a regular basis. While not yet integrated into the classroom, Rebecca was willing to catch a bus and spend time with the Assistant Principal. Plans are in place to gradually increase time in the classroom.
Conclusion
To illustrate the therapeutic approach of the PUP program we have reported a case that had a successful outcome. The mother had a number of strengths and was able to take protective action. This was particularly important to ensure that the two girls were not exposed to escalating domestic violence. However, not all families have such a positive outcome. It is important to emphasize that in the research trials of the program we have found that approximately one-third of families did not make a clinically significant improvement. Whether these families would have responded to a different therapeutic approach or whether they did not have the capacity to respond to any intervention is an important question and one that warrants further research.
It would be irresponsible for the safety and well-being of children to suggest that participation in any one parenting program can guarantee that families will achieve a minimally acceptable level of competence. For this reason we have argued that the PUP program is more responsibly employed within the context of an assessment of a family’s capacity to change when there are children at risk (Harnett, 2007). Despite this important caveat, it is encouraging that there is further evidence that multisystemic and intensive family-based interventions can help a significant number of high risk families. C

Sharon Dawe, PhD is a clinical psychologist and researcher with a longstanding interest in treatment evaluation in substance misuse. She is particularly interested in the role of impulsivity in the development of substance misuse problems and the treatment implications thereof.

Paul Harnett, PhD is a clinical psychologist and researcher in child and adolescent psychology. He has worked clinically for many years in child protection and his most recent interests include the application of mindfulness and related concepts to clinical psychology.
References
Brook, J.S., Whiteman, M., Zhen, L. (2002) Intergenerational transmission of risks for problem behaviour. Journal of Abnormal Child Psychology, 30, 65-76.
Dawe, S., Frye, S., Best, D., Lynch, M., Atkinson, J., Evans, C., Harnett, P.H. (2007) Drug Use in the Family: Impacts and Implications for children. Australian National Council on Drugs, http://www.ancd.org.au/publications/pdf/rp13_drug_use_in_family.pdf
Dawe, S., & Harnett P.H. (2007). Reducing child abuse potential in methadone maintained parents: Results from a randomised controlled trial. Journal of Substance Abuse Treatment, 32, 381-390
Harnett, P. H. (2007). A procedure for assessing parents capacity for change in child protection cases. Children and Youth Services Review, 29(9), 1179-1188.
Harnett, P. H., Dawe, S., & Rendalls, V. (2005). The Parents Under Pressure Program: Therapist’s Manual. Brisbane: Griffith University.
Hogan, T. M. S., Myers, B. J., & Elswick Jr., R. K. (2006). Child abuse potential among mothers of substance-exposed and nonexposed infants and toddlers. Child Abuse and Neglect, 30, 145-156.
Jacobson NS, Traux P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology; 59:12-21
Whitaker, R.C., Orzol, S.M., Kahn, R.S.  (2006). Maternal mental health, substance use, and domestic violence in the year after delivery and subsequent behavior problems in children at age 3 years. Archives of General Psychiatry, 63, 551-560

Comments

Add New Search RSS

Write comment
Name:
Email:	do not notifynotify
Title:
	Please input the anti-spam code that you can read in the image.

Powered by !JoomlaComment 3.26

3.26 Copyright (C) 2008 Compojoom.com / Copyright (C) 2007 Alain Georgette / Copyright (C) 2006 Frantisek Hliva. All rights reserved."

---