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(p. 211) Pre- and Perinatal Intervention for Substance Using Mothers 

(p. 211) Pre- and Perinatal Intervention for Substance Using Mothers
(p. 211) Pre- and Perinatal Intervention for Substance Using Mothers

Zack Boukydis

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Subscriber: null; date: 16 January 2019


There has been increasing recognition that new models of substance abuse treatment are needed for women who are mothers (Finkelstein, 1996; Kerwin, 2005; Osterling & Austin, 2008) and especially for women in the pre- and perinatal period (Jansson, Svikis, Lee, et al., 1996; Ashley, Marsden & Brady, 2003; Suchman, Mayes, Conti, Slade, & Rounsaville, 2004; Twomey, Soave, Gil, & Lester 2005; Suchman, Pajulo, DeCoste & Mayes, 2006; Armstrong, 2008). Fifteen years ago, in a paper titled “Keeping Mothers and Infants Together,” my colleagues and I stated that, whenever possible, women involved in illegal substance use during pregnancy should not be separated from their infants following positive toxicology screens at birth but should instead be supported with adequate and comprehensive services (Lester, Affleck, Boukydis et al., 1996). The services that we advocated were innovations in treatment programs whose purpose was to transform existing models of drug treatment, support mothers and infants, and remove barriers to growth in the developing attachment relationship.

Over the years since our “Keeping Mothers and Infants Together” paper was published, there have been larger, more comprehensive studies of factors influencing the development of substance-exposed infants, including the caregiving environment and the early attachment relationship (Seifer et al., 2004; Mayes and Pajulo; 2006; Sheinkopf et al., 2006). Parallel to these studies with their developmental and attachment-based foci, there have been studies of different forms of treatment that include, not only examination of effects of maternal drug use status and psychological functioning, but also the concomitant effects on their children’s developmental status over time (Jones, 2006). Accumulating evidence indicates that, when women are able to be in treatment with their children, there are lower rates of relapse (Roberts & Nishimoto, 1996). Furthermore, when treatment programs include a parenting component and services for children and families, there are higher rates of treatment success, better developmental status of the children, and other indicators of family stability (Roberts & Nishimoto, 1996; Szuster, Rich, Chung, & Bisconer, 1996; Kaltenbach & Finnegan, 1998; Jones, 2006).

This chapter focuses on the development of an intervention for substance abusing women in residential treatment. The intervention includes a prenatal and a postnatal component that together support the mother–infant relationship in the perinatal period. The intervention was established based on communication with parents, observations of parents and their at-risk infants, and assessment of infant (p. 212) neurobehavior. In this context, the neurobehavioral assessment combined traditional evaluation of infant reflexes and motor tone with observation and assessment of infant attentional and regulatory abilities (Lester & Tronick, 2004). The intervention was developed and then integrated into ongoing drug abuse treatment.


Teratogenic versus Transactional Models of Infant Development

Early on in the study of substance abuse and parenting, there were reports of the incidence of damage to organ and brain structures in substance-exposed infants. These findings were paralleled by a tendency in the public to envision substance-exposed infants as having moderate to severe organic damage. The stereotype included a morose picture of infants who were extremely irritable, underweight, and very difficult to soothe (Mayes, Granger, Bornstein, & Zuckerman, 1992).

The next generation of research (Lester, Tronick, LaGasse, et al., 2002) involved larger samples than those in the original reports and gave rise to a dialectic between what came to be known as teratogenic versus transactional models of behavior and development of substance-exposed infants (Hans, 2002; Sameroff, 2004; Mayes & Pajulo, 2005). (The teratogenic models assumed drugs in the bloodstream in pregnancy were most likely to injure cells and cell differentiation, while the transactional models assumed that drugs may affect neurotransmitter mechanisms and may or may not be compensated for by early environmental influences.) In addition to ongoing efforts to determine biological compromise in pregnancy (i.e., teratogenic effects), another focus (i.e., transactional) was on issues related to interactions between infants (sometimes with neurobehavioral vulnerabilities) and their early caregiving environment (Lester, Bagner, Liu, Lagasse, Seifer, Bauer et al., 2009). Here, too, there has often been a lag in perception and understanding from the public at large, treatment providers, and women themselves about the behavior, early development, and caretaking needs of substance-exposed infants (Kuecks-Morgan, 1999; Lester, Boukydis, & Twomey, 2000).

The interventions described in this chapter had to address the potential misperceptions not of only mothers about their infants, but also of treatment providers about what kinds of direct interventions and services were needed to treat and support women and their infants. The infants might have had needs that could be addressed by the healthcare and early intervention system but also had issues that were commonly referred to (by developmental specialists) as challenges in early regulation (Lester & Tronick, 1994).

The challenges in “early regulation” involved not only the infant’s neurobehavior but also the infant’s mother who was new to recovery and in some ways a neophyte in learning to recognize, hold, and attend to her own emotional reactions. Consequently, both members of the dyad were often having challenges in early regulation. A new treatment model had to respect what was known about regulation of the individuals in the dyad while also attending to and supporting the co-regulation of perceptions, interactions, and attachment.

(p. 213) Early Interaction Between Mothers and Infants

Many studies of mother–infant interaction in the population of substance using women and their infants indicate problems in maternal behavior—particularly with reading infant signals; effective soothing and management strategies; and successful management of daily cycles of feeding, sleep, and play (Kaltenbach & Finnegan, 1998; Pajulo, Savonlahti, & Piha, 1999; Pajulo, Savonlahti, Sourander, et al., 2001; Savonlahti, Pajulo, Ahlqvist, et al., 2005; Tronick et al., 2005). These early difficulties can lead to increased parental stress, maternal reactivity, lowered maternal self esteem, difficulty arranging the environment to meet the infant’s needs for appropriate stimulation, and difficulty in the early formation of mother–child attachment (Egeland & Erikson, 1990). The perinatal period is a critical time for supporting women as they take on responsibilities of parenting while learning the emotional lessons necessary for themselves in treatment and recovery (Jannson, Svikis, Lee, Paluzzi, Rutigliano, & Hackerman, 1996; Pajulo, Suchman, Kalland, & Mayes, 2006; Mayes, Magidson, Lejuez, & Nicholls, 2009).

Clinical Understanding of the Mother’s Representations

In a simple sense, an intervention must not only help a mother read and interpret her infant’s states and requirements for soothing but also help her process and change her emotional reactions, which, at times, may prevent her from seeing her infant clearly. The representational processes of women who have used and abused substances are complex, especially because they involve the mother’s view of herself in relation to her infant. In Stern’s (2004) normative perspective on the “Motherhood Constellation,” there are several central questions involving women’s thoughts about themselves as they move through pregnancy and give birth:

  1. 1. “Will I be able to keep my baby alive and growing?” (Life Growth theme);

  2. 2. “Will I be able to have a satisfying and sustainable emotional engagement with my baby?”(Primary Relatedness theme);

  3. 3. “Am I capable of providing a nurturing environment, a home life for my baby?” (Supporting Matrix theme) and

  4. 4. “Will I be able to change or transform my self-identify to support the other three functions?” (Identity Reorganization theme).

There are potential variations to these themes with women who have had a long period of trauma and substance use. The following version of Stern’s motherhood, called Motherhood for Women in Recovery, was developed accordingly:

  1. 1. Do I have the inner emotional resources (and who are my models of stable secure mothering?) to keep my baby alive and growing? (Life Growth theme);

  2. 2. As I heal the troubles of my own past, how will I be able to keep myself open to my baby’s emotional signals and emotional needs and learn to be her secure base while I am learning to be a secure base for myself? (Primary Relatedness theme);

  3. (p. 214) 3. How can I, who survived in transitional, sometimes chaotic and dangerous, environments, learn to provide and maintain a stable “home” life for myself and my baby? (Supporting Matrix theme); and

  4. 4. When and how will I learn to love and respect myself enough (not denying but realistically accepting my addictive patterns) and see myself as an adequate and loving mother for this baby? (Identity Reorganization theme).

These modified themes are one example of how training for drug abuse treatment staff can be structured to introduce staff to important issues related to child development, mothering, and the fundamentals of infant mental health (see below). Importantly, these questions have formed the basis for staff reflection and discussion, including how accurate or representative the questions are; how they might be over-generalized (e.g., viewing all women who use substances during pregnancy this way); how they might serve to blind clinicians to a mother’s true, often hidden, experience; and how they might help clinicians understand mother–baby interactions. Also central to this questioning is a model that views change in a woman’s representational process as an important mediator of her developing ability to understand her infant’s neurobehavior and engage in responsive interactions that are likely to promote her child’s optimal development.

The Perinatal Intervention

A Clinical Vignette: A Traumatic Event in a Baby’s Life and His Mother’s Changing Representations of Herself

In my capacity as a medical school and hospital-based applied researcher and clinician, I served as a consultant to a residential drug treatment program where women in recovery lived with their infants. The drug treatment program was in Providence, Rhode Island. Willie (pseudonym), at five days of age, appeared to his mother and the clinic staff very dusky in skin color and was very labored in his breathing. He and his mother were rushed to hospital, where, after repeated attempts to stimulate his heart and breathing, he was pronounced dead. I arrived at the hospital at this time to find his mother and family grieving. While we sat, a doctor entered the waiting room to say that, miraculously, Willie’s heart had begun beating while he lay on the examining table, that he was being helped to breathe, and that he needed to be rushed to a larger hospital for emergency heart surgery. Although one can never truly know, some doctors believed that a duct in Willie’s aorta that usually closes in the first days of life (permanently changing blood circulation from fetal circulation to post-birth, heart-pumped circulation) had reopened during the moments following the stoppage of heartbeat and breathing. There was probably a relaxation of muscle tone, the duct reopened, blood began to circulate, and Willie’s heart somehow began to beat again. It’s easy to imagine what an immensely powerful experience this was for Willie’s mother, family, and all of us who were present.

Three months later, I waited with the staff and residents of the program for Willie and his mother to return from his second trip to the hospital for corrective surgery. When he arrived in his infant seat, Willie looked at everyone curiously, and then (p. 215) smiled the brightest smile. Most cried and everyone laughed and smiled. Here was this baby who had almost died, and who had since been through two major heart surgeries, beaming at us.

Months later, his mother spoke about this time with Willie as the turning point in her recovery from severe drug addiction. She was so deeply moved by Willie’s will to live, and slowly realized that if he, who was in some ways so helpless and small, had the will to live, then she could only have a will to live also. As she loved Willie, she could begin to love herself. In a talk with me, she said that she had begun to identify with, hold, and nurture the willful, still alive, child in herself that survived all of her traumas. She no longer could see herself as just wounded, bad, guilty, and shameful.

While this story has unique elements, one central theme is that, as parents recognize (and hopefully identify with) key facets of newborn neurobehavioral functioning, their view of themselves as someone who produced a wounded child with a poor future may be genuinely challenged.

Intervention Objectives

Inherent in this intervention focusing on looking at the infant with mothers are the following touchstones for consultation:

  1. 1. See aspects of the infant that are truly endearing;

  2. 2. Recognize aspects of the infant’s behavior and functioning that are adaptive and organizing, and

  3. 3. Be realistic about concerns (not pathologies) in functioning, but also

  4. 4. Give the message that the infant will be caringly and intelligently watched and that the parent will be “teamed up with” by providers who will help the mother care for her baby (Boukydis, 2012).

Developmental Principles

Multilevel Intervention

As drug treatment services for women advance, there is an ongoing need for differentiation among models of infant/child development, especially in terms of how they understand and address issues of risk and resiliency at multiple levels (e.g., individual, dyadic, triadic, and family) when substance use and abuse is a major disruptive influence (Lester, Masten, & McEwen, 2006). For example, in a review of six published reports of outpatient interventions aiming to enhance the caregiving skills of substance-abusing mothers caring for children between birth and five years of age, Suchman and colleagues (2006) found that only one intervention targeted change at multiple levels (e.g., women’s emotional reactions to their infant as well as infant behavior; Field et al., 1998). The intervention described in this chapter also aimed to integrate advanced understanding of infant neurobehavior in the pre- and perinatal period with careful attention to changing women’s representational and emotional reactions to their infant’s behavior.

(p. 216) The Four A’s of Infancy

In a paper titled “Four A’s of Infancy,” Lester and Tronick (1994) gave an important conceptual framework for the neurobehavioral functioning and development of substance-exposed infants. The Four A’s are:

  1. 1. Attention, which refers to perceptual abilities that relate to the intake and processing of information from the environment,

  2. 2. Arousal, which includes control and modulation of behavioral states from sleep to waking to crying, ability to display the entire range of states, excitation, and inhibition of incoming stimuli,

  3. 3. Affect, which relates to the development of sociality and emotion, the mutual regulatory processes of social interaction and social relationships, and

  4. 4. Action, which indicates motor function, the development of fine and gross motor skills, and the acquisition of knowledge and social exchange through motor patterns.

The Four A’s provide the basis for training interventionists to use neurobehavioral assessment to guide parents, who are often faced with learning to interpret the patterns of behavior of their infants while facing extra challenges in early parenting (e.g., managing crying, establishing functional and satisfying feeding, and developing a daily, predictable rhythm in infants’ lives). A later-developed phase of the collaboration involved establishing referrals to a hospital-based Infant Crying Sleep and Behavior Clinic (Boukydis, High, Cucca, & Lester, 1997) to support women whose infants have excessive crying, colic, reflux, and early sleep and feeding concerns.

The Four A’s framework is also integral to training drug treatment staff who are learning ways to view and support women new to recovery who are adapting to motherhood for the first time as “clean and sober” parents. The Four A’s has been combined with a sensory processing framework (see Williamson & Anzalone, 2001) for use in early intervention and has been adapted into a training curriculum for protective service personnel who are required to screen substance-exposed infants in foster placements (Boukydis, 2012).

Early Intervention

Early parent–infant transactions are also considered to be major influences on the development of individuals and dyads (Waschlag & Hans, 1999; Sameroff, 2004; Seifer, Lester, LaGasse, et al., 2004). Therefore, if prevention and/or intervention are warranted, intervention is started as early as possible in the child’s development to support the dyad.

Affect Regulation

At-risk infants face multiple vulnerabilities in their affect regulation and emotional arousal that can contribute to developing problems in dyadic interaction (p. 217) and regulation and contribute to possible attachment disorders later on (Lester, Bagner, Liu, et al., 2009). Infant affect regulation is therefore an important focus of assessment and intervention.

Sensitivity to Infant Cues

Parents who persistently misread their infant’s signals (often called “mismatches in perception”) have a higher likelihood of having children with developmental problems at later stages, including attention difficulties, learning problems, and lower cognitive attainment (Lester, Boukydis, Garcia-Coll, et al., 1995; Scheinkopf, Lester, LaGasse, Seifer, Bauer, Shankaran et al., 2006). The intervention therefore incorporates a focus on assessing and improving the parent’s cue recognition and sensitivity.

Key Touchpoints

Touchpoints are periods during the first years of life in which children’s spurts in development result in disruption in the family system (see Brazelton & Sparrow, 2006). For at-risk dyads, touchpoints can be critical points of intervention. Two key touchpoints in the developing parent–infant relationship are addressed in the current intervention model—prenatal and neonatal periods. A third touchpoint—the second- to third-month period that includes a “biobehavioral shift” in infant neurobehavioral regulation, was later incorporated into the collaboration with the drug treatment program.

Intervention Planning and Development

During initial intervention planning, there were several issues to address:

  1. 1. Modifying existing services (i.e., How to modify existing services provided by the drug treatment program to support development of the child and the mother–child relationship);

  2. 2. Incorporating drug treatment professionals into the infant mental health service (i.e., How to train drug treatment professionals, who had very little training in infant development, parenting of young infants, or infant mental health practice and supervision, to integrate this work into their drug treatment framework and practice);

  3. 3. Integrating infant mental health and drug counseling (e.g., How to integrate each woman’s ongoing drug counseling with the dyadic observations and infant assessments; how to insure that women’s reactions during mother–infant consults could be processed and integrated into drug counseling sessions, and how discoveries made in drug counseling might be brought into mother–infant consults); and

  4. 4. Development of new services (i.e., How to devise new services within and collateral to the program to support the child and the mother–child relationship).

(p. 218) The response to these questions during early planning and after the initial evaluation led to a number of innovations that had both a developmental focus and the intention to support the mother–infant relationship.

Perinatal Intervention

The perinatal intervention was developed first and involved consultants providing co-therapy for mother–infant dyads. Consultants also provided in-service training in infant development and principles of infant mental health for treatment program staff and drug counselors (Boukydis, 2002). The intervention also involved consultation on videotapes of mother–infant interaction and referral to a hospital-based clinic for crying, feeding, and sleep concerns.

Ultrasound Consultation

Following the development of the perinatal intervention, a prenatal ultrasound consultation was also established so that, for many mothers, the initial contact with the consultant during pregnancy included an ultrasound consultation that provided an opportunity to learn about mothers’ reactions to seeing their baby during the ultrasound.

Intervention Description

Intervention Providers

The work described in this chapter involved enlisting the expertise of colleagues who studied the developmental outcomes of substance-exposed infants and the importance of developing effective models for supporting and consulting with parents of at-risk infants (Das Eiden & Reifman, 1996; Lester. Boukydis, & Twomey, 2000; Lester & Tronick, 2001). Expertise in the intervention was further enhanced through a collaboration with interested treatment providers in developing new ways to support women in their early interactions with their infants in treatment programs (Lester, Twomey, & Boukydis, 2000; Boukydis & Lester, 2008; Boukydis, 2012).

Intervention Format

The primary intervention began with a two-month series of mother–infant consultations provided during residential treatment following the birth of the infant. Consultants had expertise in infant mental health and infant neurobehavioral assessment. The consultants and drug counselors worked together in pairs as a co-therapeutic team for the mother.

Initial Contact

A consultant met initially with each mother during the month prior to the baby’s birth. The purpose of this meeting was to explain the mother–baby sessions and the dual role of the consultant as a liaison between the mother and her drug counselor and between the treatment program and pediatricians who would be (p. 219) following her baby after the baby was born. The meeting provided an opportunity for the consultant to ask the mother how she had been doing with her pregnancy, how she understood and felt about her baby inside, and to insure that adequate prenatal care was being provided.

Intervention Modalities

In order to consult with mothers and their infants in the perinatal period, we used two interrelated modalities: 1) Neonatal Network Neurobehavioral Scale–based (NNNS; Lester & Tronick, 2004) parent–infant consultations (Boukydis & Lester, 2008) in a clinical intervention protocol (see Boukydis, 2012, for a detailed intervention description) and 2) Observing Infants Together with Parents (Boukydis, 2008). The intervention also derived from the Psychosocial Intervention with High Risk Infants and their Families program (Meyer, Lester, Boukydis, Garcia-Coll, & McDonough, 1994) which indicated that consultation in the perinatal period with parents including a neurobehavioral assessment and intensive case management can improve maternal reading of infant signals, as well as reduce maternal depression and costly rehopitalization.

Neonatal Network Neurobehavioral Scale–Based Parent–Infant Consults

The NNNS was originally developed by the NICHD NICU Network for use in a multisite study of the development of preterm/term substance-exposed infants (the Maternal Lifestyles Study; Lester et al., 2002; Lester & Tronick, 2004; Liu, Bann, Lester, et al., 2009). As a neurobehavioral assessment, the NNNS was designed to evaluate infant behavior on three major levels of functioning: 1) behavioral (e.g., attention to auditory and visual stimuli, states of consciousness, range of states, ability to be soothed, and irritability); 2) neurological (e.g., neonatal reflexes, motor tone and control); and 3) stress-abstinence (i.e., comprehensive checklist of 50 signs of stress in seven categories, including physiological, autonomic, CNS, skin, visual, gastrointestinal, and states of consciousness).

The NNNS was selected as a basis for the intervention for four major reasons:

  1. 1. The intervention team had extensive understanding of the value of the neurobehavioral assessment in working with caregivers of at-risk infants;

  2. 2. Use of the NNNS in a consultation emphasizes aspects of infant behavior that are closely related to maternal caregiving and attachment-related behavior;

  3. 3. The NNNS can be used to document change in infant functioning over time; and

  4. 4. The NNNS can be used both as a screen for substance-exposed infants whose mothers are in treatment programs and as a context for ongoing consultations with mothers about their infants’ changes in neurobehavioral functioning and development based on their care.

(p. 220) The NNNS includes 45 items administered in packages (of similar items; e.g., “lower extremity reflex package” includes all reflex items administered to the feet and legs). In addition, there are 21 summary items that are intended to reflect overall functioning during the exam. The NNNS is appropriate for substance-exposed, pre-term and full-term at-risk infants 32 to 44 weeks’ gestational age.

Using the NNNS (see Boukydis, 2012 for further details) as a context for watching the infant’s response to handling allows the parent and consultant to observe and comment on the specific areas of functioning that can also be documented in the NNNS scoring system (e.g., efforts to achieve homeostasis, irritability and crying, unique ways of signaling stress, efforts to self-soothe, availability for interaction, emerging developmental steps, and so forth). After each session, these dimensions of infant functioning were jointly summarized by women and the consultant on the “What Happened Today” form (Boukydis, 2012) for the first month and the “My Baby’s Development” form (Boukydis & Lester, 2008) for the second month.

Observing Infants Together with Parents

This part of the intervention involves observing an infant with its mother during regular caregiving and playful, nurturing interactions. The observational framework is derived from an understanding of infant neurobehavioral organization used in three neurobehavioral assessments (Neonatal Behavioral Assessment Scale [NBAS; Brazelton & Nugent, 1995], NICU Network Neurobehavioral Scale [NNNS; Lester & Tronick, 2004]; Assessment of Preterm Infant Behavior [APIB; Als, Lester, Tronick & Brazelton, 1982] described in Lester & Tronick, 2001]

During the intervention, infant behavior is observed on five levels simultaneously: 1) physiological, 2) motor tone/motor control, 3) states of consciousness /state changes 4) interactive exchange with the personal and physical environment and 5) signs of stress and signs of regulation and self-soothing (Boukydis, 2008). In training, consultants use the five levels to observe infants alone and then in typical interactions with parents and infants. In observing infants together with mothers, the consultant often:

  1. 1. Waits for the parent to comment and then reinforces or expands on the parent’s comment;

  2. 2. Asks specific open-ended questions (e.g., “What do you think is going on for her right now?” or “What might she be telling us?”);

  3. 3. Wonders out loud about specific infant behaviors (e.g., “When she saw your face, her eyes brightened, her breathing became steadier, and she kept her focus on you; I wonder what she is telling you right now?”); and

  4. 4. Comments directly on behavior based on the interrelationships of the five levels (e.g.: (a) physiological [breathing rate, skin color, etc.]; (b) motor tone and motor control [muscle tone and smoothness or jitteriness of physical movements]; (c) states and state control [deep sleep, light sleep. drowsy, (p. 221) awake active awake; crying]; (d) interaction with personal and physical environment [responding to faces, voices, a red ball and rattle]; and (e) signs of stress and self soothing and regulatory behavior).

Women are also encouraged to attend to their own experience of their baby in play and caretaking situations and articulate their own observations (and reactions). The consultant serves as a collaborative observer who wonders aloud about what the baby may be telling the mother, as the mother might also be asking herself the same questions.

The second phase of the Observing Infants Together with Parents work involves taping caretaking and play interactions between mothers and their infants and reviewing them with mothers, and with mothers and their drug counselor. The framework for the video review and dyadic consultation was derived from Interaction Guidance (McDonough, 2004) and integrates the Observing Infants Together with Parents and a parenting group model into a video review format (for women who are receptive). Women observe each other’s babies and young children in videotapes of caretaking and play interactions made at the program site and also filmed by the women themselves (during their play, and during caretaking time with their infants in the treatment program).

There were initially two essential elements involved in developing the video review aspect of the consultation: 1) Learning to select segments that reflected strengths in early interactions between mother and baby; and 2) Developing an atmosphere of trust that so that the mother could (a) have the right emotional distance (by seeing herself and her baby in the video segment), (b) explore and reflect on her immediate reactions to herself as mother and to her baby’s behaviors), and (c) explore “deeper” reactions that might relate to her previous history of parenting and being parented.

Intervention Evaluation

The intervention was evaluated in a residential drug treatment program in Providence, Rhode Island (see Boukydis & Lester, 2008, for a detailed report). Women entered the treatment program in late pregnancy or with a young infant. The program offered drug treatment, parenting groups, on-site child care, health care for infants and mothers, life-management skills, job training, and extensive follow-up during post-residential treatment. The evaluation involved women who entered the program in the last trimester of pregnancy and who remained in treatment after their infant was born.

The format for the intervention involved two sessions (one Observing Infants with Mothers and one NNNS-based) per week during the first month postpartum and one session per week during the second month. Depending on the dyad’s needs, the evaluated intervention phase was followed by a referral to a hospital clinic, Infant Behavior Sleep and Cry clinic, screening and referral to early intervention or ongoing observations and infant–mother dyadic consultation based on Interaction Guidance (McDonough, 2004).

(p. 222) Perinatal Intervention During the Evaluation Study

The sequence of sessions for mothers in the evaluation study was as follows:

  1. (1) Introduction, establishing rapport, NNNS- based consultation, and joint completion of “My Baby’s Day” form;

  2. (2) Observing Infant Together with Parent with emphasis on managing feeding and soothing, follow-through on issues related to soothing, reading the infant’s behavior on all five levels, joint completion of “My Baby’s Day,” and videotaping infant behavior for later review (and to show the infant to family and friends).

  3. (3) Joint session with mother, consultant, and drug treatment counselor to provide an update on infant‘s response to input, handling and soothing.

  4. (4) A consultation session called Observing and Documenting my Baby’s Development.

Study Design

The evaluation consisted of analysis of group data from sequential cohorts of women who entered the program during the last trimester of pregnancy. The first three admissions were assigned to the Standard Care (no intervention) group, the next three to the Intervention, and so on. In order to fulfill screening and data collection requirements, the NNNS was completed on Day Five following delivery for all infants, but mothers in the Standard Care group did not observe the NNNS. (The screening using the NNNS was a requirement to make referrals, when necessary, to the pediatric practice that provided pediatric care to the infants in the program.) The Standard Care group received all services provided at the time except for the intervention.


Sixteen mother–infant pairs were assigned to the Standard Care condition and fifteen to the Intervention condition. Program staff did not know about the study per se; and infants in the Standard Care group received an NNNS screening and clinical status feedback, which took the place of the early intervention sessions with the women and infants. Program administrators selected counselors who would be involved in the standard care or intervention conditions with mothers. The ethnic composition for both groups was nearly identical (NNNS consultation 1st#; Standard care 2nd #: African American, 42%–45% Caucasian, 28%–30% and Hispanic 30%–25%). The groups did not differ significantly on maternal age (NNNS intervention X = 27.9 years; Standard care X = 28.2 years); or number of years of schooling (NNNS intervention X = 10 grades completed; Standard care X = 10.2 grades completed).

Parenting Stress Outcomes

The Parenting Stress Index (PSI; Abidin, 1990) was used to measure parenting stress when infants were 2 to 2.5 months old, and the PSI short version when (p. 223) infants were four months’ gestational age. At 2 to 2.5 months, in both groups, total results of one-way ANOVAs showed that the Standard Care group (N = 15) had significantly higher scores (X = 151) than did the Intervention group (N = 16) of women (X = 134; P <.05). At 2 to 2.5 months, women in the Standard Care group had significantly higher scores on the Stress from Dysfunctional Parent–Child Interaction subscale of the PSI than did women in the Intervention group. At four months, the shortened 36-item version of the PSI was used (Abidin, 1990). The PSI shortened version yields a total score and 3 factor scores (Parental Distress, Parent–Child Dysfunctional Interaction, and Difficult Child). A sum of the Parental Distress and Parent–Child Dysfunctional Interaction scores were used for this study. Significant differences between the standard care and intervention groups were maintained, with the Intervention group mean average (X = 68.2) and the Standard care mean (X–73.1; P <.05). Based on the overall Parenting Stress Index comparisons, and the subscale Stress from Dysfunctional Parent–Child Interaction, we noted that women in the Intervention group were probably better able to read their infant’s signals, help them soothe, and experienced less stress as a result of being able to manage their infant’s crying and daily patterns of sleeping, feeding, and crying. Our analyses of NNNS summary scores at five days for both groups of infants indicated that the two groups of infants were similar in the neonatal period in overall neurobehavioral functioning, ranges of states, and irritability. It was probably not infant behavior per se that was contributing to parenting stress, but maternal ability to read and interpret significant aspects of infant behavior, and the “behavior reading” influence of the intervention (Boukydis & Lester, 2008).

Clinical Vignette: Consultation with a Mother and her Substance-Exposed Infant

A unique strength of the intervention is having an early mother–infant consultation conducted by a professional trained in assessment of high-risk infants and ways to consult with parents using the NNNS and Observing Infants Together with Parents. Clinical training for the intervention consultants involves developing their capacity to read women’s emotional availability and listen to their comments within a representational framework (common to work in infant mental health; Sameroff & McDonough, 2004). In the following vignette, a consultant responds to comments by focusing on infant behavior that is related to the physical reality of the mother’s representation. This consultation was followed by a consultation with the drug treatment counselor about key representational comments that could be followed up on in subsequent treatment sessions.

What follows is part of a transcript of an early consultation with a mother and her infant that took place on the third day of the baby’s life (details of the mother and baby have been altered to preserve confidentiality). The mother had entered residential treatment in the last trimester of pregnancy. She was estranged from the baby’s father, a man with a history of substance abuse who was also the father of her first child (two years old). She had a lengthy history of involvement with illegal substances and indicated that she used primarily cocaine and alcohol during her current pregnancy. She (p. 224) had received no prenatal care at the time of her entry into the program. During her participation in the program (2½ months) she received prenatal care, daily participation in individual and group counseling, and had stable residence and daily nutrition in the context of the residential program.

Her daughter was born at 38–39 weeks gestational age after 14 hours of labor and a spontaneous vaginal birth. Her daughter was six pounds, 15 ounces (3090 grams), was stable after birth, had Apgar scores of 6 at one minute and 9 at 5 minutes. Mother and daughter left the hospital on the second day of the baby’s life to return to the treatment program. The consultant had a consulting relationship with the treatment program that included meeting with mothers during pregnancy; regular consultations with mothers during the first three months of life; meetings with women’s counselors and the mothers; and providing training and consultation in child development, infant mental health, and parenting to staff in the treatment program.

The transcript shows the kinds of exchanges that occur during the NNNS portion of the intervention with the mother watching, commenting, and participating. The beginning segment of the consultation is presented here to illustrate which maternal representational comments were noted, addressed, and referenced by the consultant during the joint session with the drug counselor. The transcript is from the first three to five minutes of the session. Representational comments noted by the consultant are underlined and subtle emphases by the consultant are in italics. The transcript begins one hour after the beginning of the consultation meeting, during which time the NNNS assessment had been completed (n.b.: not all NNNS items are noted in this segment). The segment begins with the baby dressed and lying on the bed beside the mother.

Mother (M): She’s so precious.

Consultant (C): I’ll say.

M: (to the baby?) God bless you.

C: (about the baby?) Some yawning.

M: Yep, one of my miracle babies.

C: I’ll say. You said right after she was born you looked her all over to make sure she was all there?

M: Oh, yeah.

C: When she was awake, what was she doing?

M: She was smiling, she was looking all around. She was holding her head up. I don’t know what to expect, I’m just trying.

C: Yeah you sure are. Well how about, if it’s all right you could put her back in her crib, I’m going to look at her with you. You said you wanted to film her for your family, right? (Consultant puts baby in crib; and consultant and mother watch)

M: Yes

[NNNS item: lower extremity, foot reflexes—basic reflexes of the feet and ankles]

C: The first thing I do is just watch her foot and press on the balls of her toes. See, her toes curl in, then I go on the outside of her foot and her toes—are spreading out. See? Now I’m just sort of feeling the strength in her muscles while I do these things. (p. 225)

M: Okay.

[NNNS item: leg extension and recoil: extending the infant’s legs and seeing how they “rebound” or recoil]

C: Okay. Now we can see she’s got strength, strength in the legs. There we go.

M: Hmm Hmm.

[NNNS item: popliteal angle—moving each leg upward toward the trunk, and noting how far the leg bends naturally]

C: Now we’re just going to undo a side of her diaper. And I’m going to just carefully put her leg up and see how it goes up. She fussed a little bit, but now while I’m handling her she seems to be okay and is settling down.

M: Baby dear

[Scarf sign reflex; (pulling an arm slowly across the chest; to evaluate tone in the arm and shoulder); arm extension and recoil (extending the arms beside the body and letting go—to see the “bounce back” or recoil of the arms)]

C: Mama’s calling you, can you hear her voice? Yes, she settled when she heard your voice. I’m going to do that same kind of thing with her arms now. Just sort lift them up then stretch them down. Now with one hand I let go … and it comes back up … the other … and it comes back up.

[NNNS item: Rooting and evaluation of sucking]

C: Okay and I stroke your mouth on the side. Oh, okay you know how to root don’t you?

M: Yeah. She’s really pulling on the nipple of the bottle.

C: Oh boy, Okay now here we go. What’s she doing she’s playing games with me now. She is a really strong, steady sucker.

M: Oh yes.

[NNNS item: pull to sit (carefully support infant sitting up) and trunkle tone (infant lying over the hand to see tone in the infant’s trunk)]

C: So we’re going to watch while we sit her up. Oh, you’re trying to get your head up aren’t you? Baby, we are waking you up, yes we are.

M: Hey mama, wake up mama.

[NNNS item; put infant down on front; observe crawling reflex]

C: Okay, I’m going to put her down slowly on her front. See what she does. Wow, she can get her head up there. And she gets her head over to one side, to make sure that she can keep her nose and mouth clear. She’s got her knees up underneath. She’s already kind of trying to move her legs like early crawling motion … if I kind of press on her heels—there she sort of pushes up.

M: Wow, she’s only three days old and she can do all of that!

The NNNS-based consultation continues, with NNNS Orientation items: looking at consultant’s (and mother’s) face, watching face and voice; looking for voice, and so on.

Summary of the Assessment

What follows is the actual summary completed collaboratively between the consultant and mother on the “What Happened Today” form. The emphasis here is on (p. 226) finding a common language that reflects what the mother and consultant saw and commented on during the session. The objective is to have the mother contribute to the summary and endorse what is said. The consultant assures that the comments validate some of the mother’s observations and concerns. The consultant also insures that the comments include implications for caregiving.

What Happened Today (Summary)

  1. 1. She is truly a joyful baby. She wakes up slowly without immediately crying. She moves her arms and legs smoothly.

  2. 2/3. Maybe she didn’t appreciate being woken up and she fussed. This could be her way of saying, “If you do this, do it a little slowly and gently; or I will get more worked up.”

    Right now, we agreed that she is a calm baby; and we will see if she stays that way in the next days.

  3. 4. You (mother) have said that when she fusses, you can hold her in your arms and she calms easily when she can feel you. We saw her fuss several times; but with your voice and once, my voice (consultant), she could calm down easily.

  4. 5. There were several times while we looked at her that she fussed; but she brought her fist to her mouth and settled down. You (mother) said; “already she can do this!”

  5. 6. During this time, she tried to wake up, but stayed a bit sleepy. We agreed this was probably a sign that she needed more rest. Tomorrow we will look at her again; and you agreed to watch when she wakes up what she likes looking at (in addition to you!).

  6. 7. She calmed to your (mother) voice; and looked for you; She did the same thing for me (consultant); and we saw her turn her head to find me, and my voice, several times.

  7. 8. She likes being held by you (mother); soothed by soft stroking on her back; and she likes your voice.

  8. 9. She is beginning to wake up and look at you (mother) more; she can lift her head; and when I (consultant) put her down; she turned her head to the side to keep her mouth and nose free.

  9. 10. I (infant) have shown that I am starting to wake up and will probably be more awake.

  10. 11. She (infant) says: “I am very good at eating from the bottle with a regular strong suck. You (mother) give me a break from sucking/eating every ounce or so put me on your shoulder and rub my back. Sometimes I burp; sometimes I don’t.” You (mother) are thinking about the “rhythm” of my day; when I wake up; when I eat; when I am awake; and when I need to sleep.

Salient Consultant Notes on Maternal Comments

This section highlights what the consultant kept track of in the mother’s comments that had to do with representations of the baby.

(p. 227) One of my miracle babies.

There are potentially several layers to this statement: It may be a miracle to the mother that baby appears alive and intact given her extensive drug use during this pregnancy. It may also be a miracle that this baby was the second child born while the mother was using drugs during pregnancy. One might wonder how miraculous this is given that there might be problems not evident now that will appear later. Might the mother also consider her a miracle because the baby is alive, with her own will and personality? Might the mother also be wondering, “Can I take care of this miraculous baby? Given how I was treated by my mother, will it take a ‘miracle’ for me to be able to care for her and help her grow?

I don’t know what to expect, I’m just trying.

Earlier in the session, the mother had acknowledged that her first child had been taken into protective custody and placed with the mother’s aunt following birth. (She saw her baby only once in the first three months of life). This statement may have several possible layers: “I genuinely don’t know what to expect because my first child, a boy, was not with me after he was born,” or “I am trying. I want to care for her, learn to care for her and be her mother, and I have many feelings, including joy, fear, doubt, guilt.”

Wow, only three days old and she can do all that!

There are many potential facets to this comment, including a genuine appreciation for what the mother saw her baby doing during the consultation, uncertainty about what her baby can do and what the developmental progression is, and the absence of a child to whom she can compare her baby (not having seen her first baby at all for the first two months of life).

Vignette Summary

In summary, this brief vignette illustrates how the NNNS-based consultation can elicit many reactions or representations from the mother, and the value of: 1) consultant attention to these comments, both immediately in response to the mother and in mental notes to address later during the session; and 2) following through on these representational comments to help the mother become aware of the many facets of feelings connected to the baby and her experience with the baby (while also holding a steady course in recovery and as a mother). Each of these comments formed the follow-up discussion between the consultant and the drug counselor. From this discussion, the drug counselor was more cognizant of ongoing issues that this mother had both about becoming a mother at the present time and about the influence of her mothering history and drug-taking history on her current functioning.

In this program, it was clear that each woman has her own internal emotional processing time course. Some responses could be responded to both verbally and “interactively” with the baby; and some reoccurred, for the mother, for many weeks and months.

Building Collaborations with Drug Counselors

The NNNS Consultation

A summary for each session (described above) was created for the woman’s drug counselor and joint sessions occurred for follow-up. The drug counselor was given (p. 228) the summary and reviewed it with the consultant before her next session with the mother. Mother, drug counselor, and consultant (when invited) watched the tape.

In-Service Training on Child Development and Mothering Transactions

The drug counselors participated in an in-service training program based on an infant mental health curriculum (Boukydis, 2002) and reflective supervision (see below). An important experience gained from this intervention was the consideration of what women needed in early consultation and what it takes to integrate the early consultations with ongoing drug counseling.

Integrating Observing Together into Dyadic Therapy

The collaboration between the consultant and treatment staff led to three innovations:

  1. 1. We integrated models of child development and parenting with key issues in drug counseling. For example, when the treatment staff was reviewing Brazelton’s Touchpoints (Brazelton & Sparrow, 2006) and learning about key changes in development that were “more likely” to be unbalancing or challenging to the woman’s self confidence as a mother, they also considered whether and how these challenges might also trigger a relapse. In training this became known as the Recovery Touchpoints model.

  2. (2) We combined anticipatory guidance and anticipatory relapse prevention (envisioning next developmental attainments and how they might be challenging, disruptive, and trigger anxious reactions that could lead to relapse).

  3. (3) We used the collaborative model between consultant, mother, and drug counselor along with videotaping of mother–baby interactions to (a) explore the mother’s emotional responses to the baby’s crying as potential triggers for relapse and (b) define alternative self care strategies (and caretaking responses) when similar emotional responses occurred over time.

Our collaboration also anticipated the movement from essentially processing emotional content related to the mothers’ own history of being parented à la Ghosts in the Nursery (Fraiberg, 1975) to also searching for who in the woman’s life she could identify with as a role model for mothering and parenting à la Angels in the Nursery (Lieberman, Padron, VanHorn, & Harris, 2005). In the early stages, while the collaboration predated Lieberman’s publishing of “Angels in the Nursery,” women’s search for mothering role models became a touchstone of the work and a common ground between the original intervention model and the evolving understanding of the drug treatment staff.

The Prenatal Ultrasound Intervention

During the perinatal intervention, we were in the initial stages of developing an intervention for pregnant women in the second trimester of pregnancy. This (p. 229) intervention involved looking together with the woman at her baby during an ultrasound screen and became known as “ultrasound consultation” (Boukydis et al., 2006; Boukydis, 2006). Many of the influences on how the consultation was conducted were the same as for the perinatal consultation and included the same principles for watching fetal behavior as the Observing Infants Together with Parents and NNNS-Based Consultation.

At the time, with improvements in ultrasound technology, (Salisbury, Fallone, & Lester, 2005) it became possible to observe: 1) the appearance and physical features of the fetus, 2) fetal movement and activity, 3) fetal sensory exploration (e.g., stroking its own face; licking the uterine wall), and 4) response of the fetus to internal and external stimulation. In clinical publications there were also emerging accounts of women watching ultrasound screens and speculation as to how this might affect maternal–fetal attachment.

Women in the drug treatment program who entered during the second or third trimester of pregnancy participated voluntarily in the Ultrasound Consultation protocol. The protocol itself involved 1) watching the ultrasound with a trained sonographer; 2) immediately reviewing the ultrasound with women in the treatment program; 3) a post-ultrasound review with the consultant, mother, and drug counselor; and 4) ongoing processing with the drug counselor.

An initial evaluation of the ultrasound protocol itself using the Maternal–Fetal Attachment Scale (MFAS: Cranley, 1981) and the State-Trait Anxiety Index (STAI; Speilberger, Gorusch & Lushene, 1970) indicated that maternal–fetal attachment increased from pre- to post-ultrasound consultation; and state-related anxiety decreased significantly.

A subsequent randomized controlled trial in an inner-city prenatal clinic in Detroit, Michigan, comparing the experience of women who were in the Ultrasound Consultation versus the Standard Care condition, validated that those who participated in the ultrasound consultation compared with standard care had significant increases in maternal–fetal attachment and significant decreases in anxiety, and indicated the influence of the ultrasound consultation on their feelings for their baby and for attending to their own health during pregnancy (Boukydis et al., 2006).

Our clinical impression from using the ultrasound consultation and drug counselor follow-up was that women more frequently went through a process of coming to accept the pregnancy, including being able to invest in their own health care and prepare emotionally for the baby being born. The process was an emotionally challenging one for most women, but the women were “held” in residential treatment with individual counseling and groups. Many of the drug counselors, in surveys related to the new services, indicated that the ultrasound consultation helped to begin the type of recovery process for as many as 60% of women that had not typically occurred until well after the birth of their baby. This observation has yet to be confirmed in a prospective trial that implements the ultrasound consultation and perinatal intervention and follows women progress in treatment post-natally.

At the present time, the ultrasound consultation protocol is being developed for use with substance-using women in hospital prenatal clinics, combining the (p. 230) protocol with enhancements aimed at increasing maternal reflective function (Pajulo, Ekholm, & Boukydis, 2012).


Over time, the “neurobehavioral assessment” approach to talking with parents and infants has evolved into a context for dyadic consultation. The intervention consultations presented in this chapter did not occur in isolation; rather, they were structurally integrated with each woman’s “program,” which included individual and group counseling. As the drug counselors participated in in-service training and reflective supervision of their own, they became more adept in a co-therapeutic modality that supported women in recovery, their early parenting, and the early attachment relationship.

The evaluation of the prenatal and perinatal interventions presented in this chapter gave some indication of possible benefits. In the past (Das Eiden & Reifman, 1996) neurobehavioral consultations in early infancy have been associated with improvement in mother–infant interaction. The next stage of evaluating these interventions that emphasize observing the infant and attending to evolving maternal representations should include ongoing observation and assessment of mother–infant interaction and the attachment relationship. Presently, two demonstration programs are being developed that expand on the current ultrasound consultation and neonatal consultation with substance-using women and their infants. Hopefully, both protocols will address unanswered questions about how, for whom, and under what circumstances the intervention is useful and effective.


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