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10/18/2018
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The Opioid Epidemic:Pregnant & Parenting WomenDiane J. Abatemarco, PhD, MSW
Presentation Learning ObjectivesThe participants will be able to:1. Understand the epidemiology of maternal opioid
dependence2. Identify comprehensive program elements of maternal
opioid treatment3. Articulate the meaning and outcomes of mindfulness
based parenting to prevent intergenerational trauma as well as to improve the quality of life for mothers and their infants and toddler
Political, Historical, Sociological, Economic Context of drug use From the 1980s – shrinking economy, deepening poverty, wider disparity
Family isolation – fewer extended families, lack of community, parents needing to work longer out of home
Destruction of the Great Society/War on Poverty federal programs to lift working class to middle class
More adverse exposures to children at risk of poverty and isolation
Greater direct marketing and distribution of pharmaceuticals to public
Results……..
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Assumptions….
Pregnancy – An active decision to battle addiction
A desire to become a good mother
Using opioids is numbing rather than getting “high”
Can stop intergenerational trauma by supporting the maternal-infant dyad
A belief that there is the ”clear blue sky” in all of us… Pema Chodrun
Maternal Addiction Treatment, Education, & Research (MATER) at Thomas Jefferson University
MATER’s History
1975 – Family Center begins
outpatient treatment program
1990 – My Sister’s Place
offers residential
treatment to 22 women +
children
2007 –Family Center
adds IOP
2015 Mindfulness
Implemented with Patients &
Staff
2016 – Transition to OBGYN,
census increases to 250
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Mother
Psychiatry
Case Manage-
ment
Individual Counseling
Group Counseling
& Education
Care Manage-
ment
Child Care &
Advocacy
Medical Care
Residential Treatment
Medical Care
Prenatal / Postpartum
OBGYN
Pediatrics
General Medical Care
Specialist care (Hep C / HIV)
Case Management
Housing Assistance
Transportation
SNAP/TANF/WICIdentification
Insurance
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Child Care &
Advocacy
Screening & Early
Intervention
CUA / DHS Support
Family Court Assistance
Parenting Education
Care Management
Outreach
Re-engagement
Intake & Orientation
Referral Follow-up
Data Collection
MATER’S Treatment Philosophy
Trauma-informed carePrevent maternal re-traumatization and adverse
childhood experiencesCompassionate approach Supporting the mother-infant dyadMindfulness-based interventions
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Census Typically 230 outpatients @ Family Center
PregnantPost partumIOPOp
Residential @ My Sister’s PlaceApproximate 21 with up to 3 children eachAdditional 4 Beds will be for transitional housing
Adverse Childhood Experiences
4.0%
38.7% 57.3%
Prevalence of ACE's
0 ACE's1-3 ACE's≥4 ACE's
Categories of ACE exposure: a comparison to local and national estimates
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Longitudinal Impact of ACE’s
Source: http://www.cdc.gov/ace/index.htm
Demographics Parent Age (years, SD) 30.6 (4.4) Race %
African American 8.6 Caucasian 74.4 Multiracial 17.0
Ethnicity Hispanic 10.0 Non-Hispanic 77.5
Education Some H.S. 32.8 HS 31.0 Some College 32.8 College 3.5
Relationship Status % Single 42.7
Partner 46.2
Married 6.0
Months in treatment (SD) 18.49 (16.71)
Number of children (SD) 3.7 (9.3)
Employment 8.8
Need for Parent Training
18
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Opioid Epidemic and Parenting
• Between 2000 and 2009, the number of delivering mothers dependent on or using opiates increased nearly five-fold, from 1.19 to 5.63 per 1,000 hospital births per year
• Barriers: unemployment, incarceration, co-morbid phys and mental conditions, stresses with abstinence
• Higher levels depression, feelings being failure, low income, low education, family type, inconsistent
• Drug use risk factor for poor parenting• Perception babies as high need, hard to take care of--
disorders of regulation and affect (maladaptive parenting)• 9/10 pregnancies unintended
Parenting and Substance Using Mothers
Mothers with substance use disorders identified as at risk for parenting deficitsAmbivalent feelingsHarsh punitive responses expressed through
yelling and threateningLack of understanding about basic
developmental issuesPerception of infant communications as
demanding and inappropriate
Practicing Safety Mindfulness for Mothers in Drug Treatment (PSMDT)
Practicing Safety Nemours/Jefferson Clinic
Philadelphia
Practicing Safety Nemours/Jefferson Clinic
Philadelphia
Mindfulness Based
Parenting Family Center Maternal Drug
Treatment Program
Mindfulness Based
Parenting Family Center Maternal Drug
Treatment Program
Enhanced referral/care
management
Enhanced referral/care
management
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Exciting AlternativeMindfulness Based Parenting
• Relational parenting intervention approach• Calls for full attention of parents when interacting with their
children• Highlights aspects of non-judgment, compassion, self-
regulation, and cultivating emotional awareness
We See Mindfulness in the Media Today
23
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Format of Trauma informed MBP 2 hours weekly over course of 12 weeks 3 mother/child dyad sessions in weeks 4,7, and 11; 45 minutes
Participating children aged 3 months to 3 years Ideal group size 10-13 mothers Focus on self-compassion, building mother’s ego and self-efficacy in
parenting Mothers encouraged to do 5-15 minutes daily mindfulness practice Adjust to trauma histories, short attention span and low literacy levels Practice Adaptations Movement Mindfulness in Daily Life
Five Tenets of Mindfulness Based Parenting
1. Nurturing oneself and one’s child2. Attuning to child’s emotional and physical needs3. Awareness of their thoughts and feelings and that of
child4. Acceptance of oneself, one’s child and circumstance5. Being able to respond wisely rather than impulsively
Mindfulness Based Parenting Group Room
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Results28
Maternal Outcomes
Perceived Stress Scale p<.0001 (mean difference=-3.17, se 0.75) Five Facets Mindfulness
Aware p<.0578 (mean difference 1.37, se 0.71)Describe p<.0005 (mean difference 2.29, se 0.63)Nonjudgment p<.0142 (mean difference 1.97, se 0.78)Nonreactivity p<.0002 (mean difference 2.26, se 0.57)Observing p<.0001 (mean difference 2.80, se 0.69)
Differential Emotional Response p<.04 (mean difference=-13.38, se 6.11)
Beck Depression Inventory p<.06 (mean difference=-3.32, se 1.68)
KIPS Total and Subscale Scores
KIPS Total F(1,68.68) = 111.25, p<.001,
d=1.20 “Building Relationships”
F(1,69.90) = 96.44, p<.001, d=1.12
“Promoting Learning” F(1,67.66) = 85.67, p<.001,
d=1.16 “Supporting Confidence”
F(1,75.75)=96.76, p<.001, d=1.20
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KIPS Total 3-way Time*ACEs*Attendance
KIPS Total 2-way Time*Mindful Parenting
Est.=0.04 (0.02), t=2.41, p=.019 Est.=0.07(0.03), t=2.33, p=.022
In Summary - the results of mindfulness training indicate….
MBP intervention associated with clinically significant improvements across quality of parenting domains
Study contributes to sparse literature surrounding dose response with mindfulness interventions (ACE/KIPS)
Clinically significant improvements across KIPS, FFM, Depression
In conclusion: what is the life course that women in treatment and their young children will face?
Good news is that comprehensive programs do have impact
MATER has approximately 90% rate of success The adverse experiences only effect the brain when
they are repetitive and without treatmentWith treatment we build resilience and have greater,
deeper insight (Example: staff who were clients)
So what’s next?
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Mindfulness in Pregnancy
6 week mindfulness course in Dept of Ob/Gyn
Identified women at risk for preterm birth
Pilot test, showed 90% retention
Mixed class of women in Substance Use Tx and those with no history of SU
Mindfulness In Pregnancy–Intervention study Outcomes:
Baseline Demographic Characteristics (N=45)
Age (years)18-24 27%25-35 64%>36 9%
RaceBlack 49%White 40%Other 11%
Education<=HS 51%>HS 49%
InsuranceKeystone 1st 84%Private/Other 16%
WICYes 58%No 40%
ReligionChristian 60%Muslim 18%
Note: 40% were receiving methadone maintenance pre-pregnancy.
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Mindfulness In Pregnancy–Delivery Data (N=30)
Birth weight, g (SD) 3029 (397)Gestational age, weeks (SD) 38.0 (2.7)Prepregnancy BMI, kg/m2 (SD) 24.5 (7.5)Gestational weight gain, kg (SD) 16.8 (10.6)Preterm, n (%) 4 (14.9)Hypertension, n (%) 7 (23.3)Gestational diabetes, n (%) 3 (10.0)Small for gestational age, n (%) 2 (7.7)NICU admission, n (%) 5 (23.8)Female newborn, n (%) 14 (51.9)
Mindfulness in Pregnancy– Outcomes
0
5
10
15
20
25
30
35
40
45
Mindfulness Perceived Stress Trait Anxiety Pregnancy anxiety
Pre
Post-I
Post-II
***
. Mindfulness improved and sustained
. Perceived stress reduced and sustained
. Anxiety reduced and sustained
. No effect on pregnancy anxiety
* *
* p < 0.03Post-I assessed 60 days (SD 18) post intervention (during pregnancy)Post-II assessed 214 days (SD 49) post intervention (after delivery)
Mindfulness in Parenting – Outcomes
Improvements in total mindfulness, perceived stress, and anxiety remained significant after adjusting for race, level of education, and WIC status.
Pre-Post Differences P-values Mindfulness: 0.0002
Perceived stress: 0.0004
Trait anxiety: 0.0160
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Five Facets of Mindfulness, Pre- and post-intervention
0
1
2
3
4
Awareness Describe Nonjudging Nonreactivity Observe
PrePost-IPost-II
* **
* p-value <0.01Post-I assessed 60 days (SD 18) post intervention (during pregnancy)Post-II assessed 214 days (SD 49) post intervention (after delivery)
Newest SAMHSA funded initiative -Supporting Women and Children with Substance Use Recovery – A family Unity Approach (SWC-FamU)
A Transformative approach to residential treatment Include families (screen for risk and case management)
Tailored mindfulness groups designed to prevent child trauma,
improve maternal treatment outcomes through family education
Mindfulness groups for adolescent children, partners, fathers of babies, and extended family members
Family dinners at MSP
Pediatric Centering in MSP
Outreach to communities of color who are underserved
Enhanced transition planning for mothers and babies
Mindfulness Dialogue for Life:Healing the Healer An innovative intervention to address the Quadruple Aim that Bodenheimer
and Sinsky address – burnout and dissatisfaction.
Daniel Martin and Diane J. Abatemarco, Co-facilitators
Use of mindfulness, reflection and inquiry to grow self-compassion and self-care
