(p. 303) Attachment and Biobehavioral Catch-up: An Attachment-Based Intervention for Substance-Using Mothers and Their Infants
Mothers who use illicit substances are nearly three times more likely than non-substance-abusing mothers to abuse or neglect their children (Chaffin, Kelleher, & Hollenberg, 1996; Kelleher, Chaffin, Hollenberg, & Fischer, 1994). Substance abuse appears to represent a specific risk factor, over and above other risk factors such as poverty and mental health problems (Chaffin et al., 1996).
Substance use is associated with a host of problematic parenting behaviors (Hans, Bernstein, & Henson, 1999; Johnson et al., 2002; Molitor & Mayes, 2010; Molitor, Mayes, & Ward, 2003). First, mothers who use substances sometimes neglect their children, failing to provide adequate social stimulation and/or failing to provide a safe, protective interpersonal environment (Hans et al., 1999). Coinciding with their high risk for neglect, many substance-abusing mothers report ambivalence about providing continued care for their children (Mayes & Truman, 2002; Murphy & Rosenbaum, 1999; Suchman, Pajulo, DeCoste, & Mayes, 2006). Second, when engaged with their young children, substance-using mothers are often less sensitive and responsive than non-substance-abusing mothers (Molitor & Mayes, 2010). Third, they are more likely than non-substance-abusing mothers to behave in frightening ways (Hans et al., 1999; Johnson et al., 2002). Each of these issues is associated with challenges for infants and young children, as described below. Therefore, it is not surprising that outcomes for children of substance-using mothers are often less favorable than for other children (e.g., Johnson et al., 2002; Molitor et al., 2003).
We have developed an intervention, Attachment and Biobehavioral Catch-up, that targets substance-abusing mothers’ risk for neglect, reduced feelings of commitment and delight with respect to caring for their children, and increased insensitive responsiveness and frightening behavior. This chapter first describes the specific ways in which substance-using mothers often parent differently than other mothers, using case examples that illustrate how the intervention targets each of the specific problematic issues. We will then describe the intervention, and finally present evidence of the intervention’s effectiveness.
(p. 304) Parenting Issues among Substance-Using Mothers
Risk for Neglect, Reduced Commitment, and Decreased Reward
Maternal substance abuse has been associated with neglect (Cash & Wilke, 2003). Preoccupation with obtaining substances and the effects of substances on mothers’ reward and motivation systems underlying parenting are among the factors leading to lower levels of commitment and delight, and the inadequate attention paid to young children.
Case Example 1: Background
Isabel was a 30-year-old heroin-addicted mother. She had two older children who had been taken from her care earlier and eventually adopted by their foster parents. At the point when she was referred to our program, her 10-month-old daughter, Cloe, was living with her. Isabel had a number of childlike and/or dissociative behaviors, including becoming absorbed in her own thoughts while twirling her hair around her finger. She had been using heroin for a number of years; when she had money, she often chose to use it for purchasing heroin, which was readily available in her neighborhood. At such times, she left her child (and sometimes a neighbor’s child) with anyone she could find in her apartment. Cloe was left in her crib or in a baby seat for long periods of time, whether asleep or not. A host of children and adults came in and out of the apartment. When Isabel was lucid, and when supported in her efforts, she interacted with her daughter; when she was not lucid, she showed little propensity to interact with Cloe or to protect her child.
Implications of maternal neglect: The primary issue identified in Isabel’s parenting ability was her extreme neglect of providing protection and basic care for her child. Although humans have probably evolved to handle a range of caregiving conditions, the experience of neglect is almost certainly outside of the range of experience-expectant conditions (e.g., Greenough, Black, & Wallace, 1987). Human young are born relatively altricial, or dependent upon mothers for help in regulating most aspects of functioning. Therefore, infants whose mothers neglect them may well adapt in ways that prove problematic to long-term functioning. John Bowlby, the architect of attachment theory, first began his study of attachment through observing young boys whom he termed “affectionless thieves” (1944). He found that these boys, who appeared callous and uncaring interpersonally, uniformly lacked a caregiver who had been committed to their well-being. Bowlby suggested that having a committed caregiver, someone who would stand between oneself and danger, was critical to healthy development.
When the substance-abusing mother neglects her young child, the child experiences a world that is highly threatening. Whereas the child is “designed” evolutionarily to depend upon his or her caregiver, he or she must navigate the world without having a caregiver upon whom to rely. Although attachment quality has received extensive attention in the literature, a neglectful or absent caregiver represents a much more fundamental problem for the child than insensitive care. At the level of regulatory functions, the natural progression from a dyadic process to self-regulation is bypassed, with (p. 305) compromises resulting from the child’s taking over functions prematurely. For example, the effective caregiver helps buffer the young child from stressors at the neuroendocrine level such that rises in cortisol are not seen in response to challenges; when the child does not have an effective caregiver, cortisol responses are seen (Bernard & Dozier, 2010; Hertsgaard, Gunnar, Farrell, Erickson, & Nachmias, 1995).
Neurobiology of Neglect in Addicted Mothers
The increased rates of neglect found among substance-abusing parents have been attributed to drug addiction’s impact on neurobiological systems associated with reward and motivation. Many of the commonly abused substances, such as cocaine or heroin, interfere with the brain systems involved in motivation, joy, and reward (Koob, 1996; Koob & LeMoal, 1997). In the case of mothers with drug addictions, the central reward systems seem to become “rewired”; drug use becomes more highly motivating and rewarding than more natural rewards, such as the parenting of one’s child (Suchman, DeCoste, Castiglioni, Legow, & Mayes, 2008). Consequently, mothers with substance abuse problems have been found to express more ambivalence with regard to the continued care of their children, and experience decreased parental motivation, compared to mothers without drug problems (Mayes & Truman, 2002; Murphy & Rosenbaum, 1999; Suchman, Pajulo, DeCoste, & Mayes, 2006).
Implications for Intervention
Anecdotally, in our work with substance-abusing parents, we have also observed that mothers report reduced feelings of commitment to a long-lasting relationship with their children. Motivated by this observation, we developed a semi-structured interview that systematically assesses the variability in mothers’ long-term feelings of commitment and investment in their children. During administrations of this interview prior to the start of our intervention program, we have observed that many mothers admit to having considered placing their children with another caregiver, such as a relative or a foster care provider. When probed further, mothers often reported feeling overwhelmed by the needs of their children, given their struggle with drug addiction, and questioned their abilities to provide a protective environment for their children.
At a behavioral level, we have observed that substance-abusing mothers often seem to show less delight in their young child’s behavior, compared with mothers who do not have substance abuse issues. In our previous work with foster mothers and infants, we have found that when mothers display delight toward their children, it elicits delight from the young child, and is highly rewarding to mothers—and certainly to children. Therefore, enhancing mothers’ abilities to take delight in their children may be instrumental for addressing the unique parenting issues pertaining to substance-abusing mothers. Because we have found that displays of delight are associated with feelings of commitment (p. 306) (Bernard & Dozier, 2010), we expect that helping substance-abusing mothers’ exhibit delight in their children may also serve to enhance their commitment to their children.
We increase mothers’ reward in response to their children primarily in the context of helping mothers learn to follow children’s lead. During the Attachment and Biobehavioral Catch-up program, mothers are encouraged to follow along and show delight in their children’s actions. For example, when reading a book together, we encourage mothers to allow their children to “lead the dance.” If instead their child prefers to play peek-a-boo with the book, we encourage mothers to follow along and celebrate their child’s efforts. In addition to praising mothers’ efforts, we highlight instances in which children seem delighted by their mothers’ involvement and participation. The interventionist comments on these moments of maternal joy and delight as they occur during the session. We also review the moments when mothers successfully take delight in their children to help mothers grasp the powerful influence they have on their children.
Expressing delight or joy in their children’s actions is often very difficult for mothers with drug addictions, who may not be used to interacting with their children in this manner. Early on in the intervention, we find that there may only be one or two brief moments in which mothers take delight in their children. However, the gentle support of the interventionist helps mothers to find opportunities in which they can offer praise, encouragement, or positive comments. Illustrating the impact of the mothers’ joy on both the children’s and mothers’ mental state becomes a powerful tool for change. By providing ongoing support and encouragement, we find that mothers become more willing and confident in their abilities to express delight in their child’s actions. Over time, their delight and enjoyment become more frequent and automatic.
Case Example 1: Intervention
Isabel’s parenting behaviors (e.g., leaving her child to obtain drugs, tuning out the child’s bids for attention) conveyed a lack of commitment to her child. In discussions with the interventionist, Isabel described how her addiction and strong drug cravings made it difficult to find the energy and motivation to care for her child. She reported that some days, it was even difficult to make sure that Cloe was clothed and fed. When asked what she does when things become too overwhelming, Isabel reported that she often drops Cloe off at a nearby relative’s house until she “gets back on her feet.” Although it was hard for her to admit, Isabel confessed that she questioned her abilities to be a stable parent for her child, and wondered if her child might be better off being cared for somewhere else.
In Isabel’s case, drug addiction clearly reduced her capacity to provide adequate care for her child. She was at risk of neglecting her child’s physical and emotional needs, her motivation and confidence in her abilities to care for her child had waned, and her drug use seemed to overtake her ability to perceive her own child as rewarding. One way that the intervention targeted this issue was to increase the number of opportunities in which Isabel could value and enjoy her child during everyday interactions.
(p. 307) During intervention sessions, Isabel was supported in her efforts to take delight in her child. The interventionist highlighted instances, even during mealtime or routine daily activities, in which Isabel could follow her child’s lead and take delight in her actions. Importantly, the interventionist praised instances in which Isabel naturally and genuinely took delight in her child during the session. When Isabel reflexively smiled in response to Cloe’s giggle, causing Cloe to smile wider, the interventionist commented on how powerful Isabel’s expression of delight was for Cloe. Playing back the video clip of this moment helped Isabel see the positive influence of her delight on Cloe. Although Isabel struggled at first, she became less dependent on the interventionist’s prompts for help to find opportunities to take delight in her child, and began to do so naturally. Toward the end of the program, Isabel remarked that her interactions with her daughter had become “the best part of her day,” and that it made her feel proud that she could have such a positive effect on her child. During a follow-up visit with Isabel, she was proud to tell our research assistant that she had been sober for six months. Although she admitted that on her “difficult days” she sometimes struggled with following Cloe’s lead and taking delight in her interactions, she seemed more invested in her role as a mother, more rewarded by her interactions with Cloe, and appeared better able to provide Cloe with a fundamental sense of protection.
Lack of Sensitive, Responsive Maternal Care
Mothers who abuse substances have been found to be less sensitive and responsive than non-drug-abusing mothers (Eiden, 2001; Mayes et al., 1997; Schuetze, Zeskind, & Eiden, 2003). This lack of sensitive care may take several forms. First, mothers may reject their children’s bids for reassurance in a number of ways, including actively discouraging the child’s bids through making fun of the child (e.g., “Don’t be a baby”) or chastising the child (e.g., “I told you not to stand on that chair!”), and more passively discouraging the bids through denial (e.g., “You’re not really hurt”) or distraction (e.g., “Look at the birdie outside”). However different these maternal behaviors appear, they all carry the message that the child should not expect the mother to respond to the child’s distress. Second, mothers may be inconsistent in their responsiveness to children’s distress. They may be responsive at times and unresponsive at others, or may be rejecting at times and appropriately responsive at others.
Case Example 2: Background
Lenora was a 17-year-old girl who had been using substances (mostly marijuana and alcohol) since she was a young teenager. She was living in an apartment with her two young children when we saw her in our intervention. When her 12-month-old daughter backed away from the interventionist (who was then a stranger to her), Lenora laughed and said, “Don’t be stupid, Callie. She’s not going to do anything to you.” She often told her two-year-old son, Caleb, that he would grow up to be a sissy if he didn’t quit crying when he separated from her. When Callie fell off the sofa and was (p. 308) visibly shaken and injured, Lenora said, “Don’t you cry—that won’t make it hurt any less.” While observing Lenora interact with her children during the first few sessions, it became clear to the interventionist that Lenora struggled with providing sensitive, nurturing care at times when her children needed her, especially when they were hurt, frightened, or separated from her. During discussions about her own parenting beliefs, Lenora reported that she believed that too much comfort and affection would spoil her children. She was convinced that providing nurturance would cause her children to be unprepared to deal with a tough world.
Implications of maternal insensitivity: As was the case with Lenora, mothers’ own histories of attachment-related experiences significantly influence their parental-related thoughts and behaviors (van IJzendoorn, 1995). Mothers who characteristically idealize their own attachment figures and attachment experiences are those who most often reject their children’s bids for reassurance (van IJzendoorn, 1995). Mothers who express extreme anger and seem overly preoccupied with their previous attachment experiences tend to be inconsistent in their availability. Mothers who both value attachment and are open and consistent in their appraisals of attachment experiences tend to be responsive to their infants’ signals for reassurance.
Sensitive, responsive maternal care is associated with children’s developing secure attachments to their mothers, whereas insensitive care is associated with children’s developing insecure attachments (van IJzendoorn, 1995). When children find that their mothers are responsive to them when they need them, they develop “confident expectations” that their mothers will be available to meet their needs. On one hand, if a child’s mother typically responds with soothing words and reassurance when the child comes to her distressed, the child will look to her with confidence in her availability when he or she is distressed. On the other hand, if a child’s mother typically rebuffs his or her bids for reassurance when distressed, the child will become less likely to turn to her when distressed.
This confidence in maternal availability is assessed in the Strange Situation Procedure, the laboratory assessment of attachment (Ainsworth, Blehar, Waters, & Wall, 1978). In the Strange Situation, children undergo a series of episodes that increasingly challenge them. Of most relevance for classifying children as secure or insecure, mothers are reunited with their children following brief (up to 6-minute) separations. Children classified as “secure” are those who turn directly to their mothers for whatever comfort they need. In the case of a child who has not been very distressed, it might take the form of a smile or verbal greeting following the mother’s return; in the case of a child who has been highly distressed, it might be running to the mother and snuggling with the mother for an extended period of time before venturing off to play. Compared with secure children, children classified as “insecure” are less confident that they can be reassured by their mothers. This might be seen in avoidant behaviors such as turning away from the mother upon reunion, or resistant behaviors such as remaining fussy even after the mother has attempted to soothe him or her. (Disorganized behaviors will be discussed in the following section.)
Implications for intervention: Whereas having an insensitive mother is not optimal, it is important to distinguish this from conditions in which the child is not confident that his or her mother will protect him or her (discussed earlier) and conditions when he or she is fearful of the mother (discussed next). Although not optimal, having an insensitive mother is not associated with as problematic outcomes as being unable to trust in the mother’s protection or as being frightened of the mother (Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley, & Roisman, 2010; (p. 309) van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999). Children with insecure/avoidant or insecure/resistant attachments represent strategies for dealing with the mother’s unavailability. Children who turn away from their mothers rather than showing their distress are probably minimizing the likelihood of more-significant rejections from mothers who are not comfortable with children’s distress. Children who remain resistant and fussy maximize chances of mothers’ responding who only respond intermittently. Thus, the behaviors are well-suited to the availability of the caregivers. One of the central targets of Attachment and Biobehavioral Catch-up is to help mothers provide nurturance to their young children. They are helped to provide nurturance even though children may not elicit it (i.e., children have come to not expect it) and even though it may not come naturally to them due to their own beliefs and values regarding attachment.
Case Example 2: Intervention
The intervention targeted Lenora’s issues with nurturance in two ways. First, given that Lenora’s children had learned to not expect her to be available, the intervention helped Lenora see that her children might need her nurturance even when they did not show it directly. Second, the intervention helped Lenora think through what made it difficult for her to behave in nurturing ways. She was asked to think of the “voices from her past” that she heard when her children cried. Through the help of the interventionist, Lenora explored how her previous experiences were influencing her current parenting. During the video-based feedback, Lenora realized that her son eventually calmed when she soothed him when hurt. She also noticed that he calmed more quickly when she soothed him than if she let him go off on his own. Through discussions with the interventionist, Lenora become convinced that her responsiveness would help her children to grow up more confident and less needy than if they dealt with their struggles alone.
Throughout the latter half of the intervention program, Lenora successfully learned to “override” her automatic response to ignore her children or tell them to stop crying (which was to do what her parents would have done), and to respond to her children’s distress sensitively. For example, Lenora would remind herself, “my baby needs me to pick her up, even though I hear my mom telling me ‘you are going to spoil that child.’” By end of the program, she expressed how much easier responding sensitively to her children’s needs had become over time.
Frightening Maternal Behavior
Mothers who use substances have been found to behave in more frightening ways with their infants and young children than non-substance-abusing mothers (Hans et al., 1999; Lyons-Ruth & Block, 1996). The behaviors range from threatening behaviors to hostile, intrusive behaviors, to odd and bizarre behaviors (Johnson et al., 2002; Lyons-Ruth & Block, 1996). For example, mothers may behave in frankly frightening ways, such as yelling at children or hitting them, or may behave in intrusive, overwhelming ways that cause children to recoil. Regardless, these behaviors have the effect of making the child frightened of the mother.
(p. 310) Case Example 3: Background
Bernice had used crack cocaine off and on for the past ten years, and had recently used methamphetamine heavily. During the first session, Bernice remarked that she was under a lot of stress and had very little patience for her children. Being the sole caregiver, Bernice was constantly trying to make ends meet and keep a roof over their heads. As an added stress, Bernice was exhausted from trying to get clean and “had no energy to deal with the trouble her kids were causing.” It was clear that Bernice was desperate to keep her children safe, but she often used tactics that were frightening. For example, when her eight-month-old put objects in her mouth, Bernice became fearful that her baby would choke. She yelled loudly, “I TOLD you not to do that! Get that out of your mouth before I smack you.” Both the little girl and her three-year-old recoiled in fear. When discussing Bernice’s past, it became clear that many of her own experiences with her mother and other caregivers (including her grandmother and foster mother) were characterized by frightening behaviors. For example, Bernice recalled getting a “beating” after she spilled a carton of juice on the kitchen floor when she was trying to pour a glass for her brother. Bernice was aware that such experiences had been difficult for her to deal with but had never thought about the effects on her ability to trust her caregivers. Furthermore, she did not see her own behaviors as frightening except in the most obvious instances.
Implications of frightening maternal behavior: Frightening behaviors like those displayed by Bernice are concerning because of their association with disorganized attachment and dissociative behavior among young children (Lyons-Ruth & Block, 1996). Children’s attachment quality is particularly affected by frightening maternal behavior. Main and Hesse (1990) have suggested that when children are frightened of their caregivers, they have an “unsolvable dilemma.” Such children are often frightened of the people whom they look to for reassurance and have a dilemma when needing to turn to them. Therefore, children’s ability to maintain an organized attachment strategy is disrupted. Indeed, a large proportion of children of substance-abusing mothers develop disorganized attachments (Goodman, Hans, & Cox, 1999; O’Connor, Sigman, & Brill, 1987; Rodning, Beckwith, & Howard, 1991; Swanson, Beckwith, & Howard, 2002).
Disorganized attachment is characterized by odd, anomalous behaviors when children are distressed and in their mother’s presence. In the Strange Situation, a number of behaviors have been noted, including the sequential or simultaneous display of contradictory attachment behaviors (such as avoidance and resistance), undirected or misdirected attachment behaviors (such as protesting the stranger’s departure from the room), stereotypies, freezing, direct evidence of apprehension of mother, and direct evidence of disorientation (Main & Solomon, 1990).
Implications for intervention. Attachment and Biobehavioral Catch-up targets frightening behavior directly. Mothers are helped to think about experiences from their own past when caregivers frightened them, whether for discipline or teasing, and then helped to monitor their own behaviors with their children, becoming aware of times when they are intrusive or frightening.
(p. 311) Case Example 3: Intervention
Bernice’s frightening behaviors were particularly concerning, given their frequency, severity, and noticeable effect on her children. After discussing examples of frightening behavior experienced by other children, the effects of frightening behavior on children’s ability to trust their mothers, and Bernice’s own experiences of being frightened of her caregivers, Bernice was encouraged to think about her own parenting behaviors that might be perceived as frightening to her children. Because Bernice felt supported by the interventionist and had developed a trusting relationship with her at this stage of the intervention, she openly considered aspects of her parenting that might be overwhelming to her children. She acknowledged that she remembered feeling frightened as a child, but didn’t realize that she might be perpetuating what she had experienced.
The interventionist emphasized that becoming aware of her strengths and weaknesses as a parent was an incredible accomplishment. Bernice and the interventionist identified moments in which Bernice responded in a sensitive manner, and observed the positive effect that it had on her children. These moments were compared with instances in which Bernice behaved in a frightening manner. Through this powerful contrast, Bernice began to monitor her behavior and practice alternative ways of responding to her children as a means of keeping them safe.
The Attachment and Biobehavioral Catch-Up Intervention
The Attachment and Biobehavioral Catch-up (ABC) Intervention was first developed for foster mothers. It targeted three key issues that we have identified as important for caregivers of children placed in foster care. First, we found that foster children tended to behave in ways that served to push caregivers away (Stovall & Dozier, 2000; Stovall-McClough & Dozier, 2004). Even when foster mothers were generally nurturing, foster children behaved in ways that served to elicit non-nurturing behaviors. More specifically, children either turned away from caregivers or were fussy and inconsolable. When children turned away from them, foster mothers behaved as if children did not need them; when children were fussy and inconsolable, foster mothers responded angrily in return.
In our clinical work with at-risk birth parents who have high rates of substance abuse, we have also observed that young children often avoid or push their mothers away at times of need. We realized that, similar to foster mothers, these at-risk birth mothers also need to do more than be responsive—they need to actually behave in therapeutic ways, seeing the “need” underlying their children’s avoidant or angry behavior. We were aware that this may be especially challenging for birth mothers who are at risk for neglect and often currently struggling with substance abuse problems, but with support and effective scaffolding to increase their (p. 312) parenting, we have found improvements in their children’s outcomes (Bernard, Bick, & Dozier, 2012).
The second component of the intervention for foster mothers was helping them provide nurturing care even when it did not come naturally to them (Dozier, Stovall, Albus, & Bates, 2001). Clearly this was an even more critical issue among birth mothers, especially those with substance abuse issues, than among foster mothers, due to the former group’s frequent histories of abuse and trauma (Breslau, Davis, & Schultz, 2003; Jacobsen, Southwick, & Kosten, 2001).
The third component of the foster mother intervention was helping mothers follow their children’s lead with delight. Foster mothers varied in how well they followed their children’s lead and how committed they were to the children in their care (Dozier & Lindhiem, 2006; Lindhiem & Dozier, 2007). Birth mothers who are substance-using very often have difficulty following their children’s lead and seem to waver in their feelings that they can provide long-term, stable care for their children (Mayes and Truman, 2002). Related to this, we see deficits in the expression of delight among many substance-using mothers, most likely due to the influence of the drug addiction on their abilities to experience joy and reward in their children (Mayes & Truman, 2002; Murphy & Rosenbaum, 1999; Suchman, Pajulo, DeCoste, & Mayes, 2006)
Finally, we had not identified frightening behavior as a critical issue among foster mothers. When we began intervening with birth mothers, especially those who used substances, this behavior emerged as striking. It was clear that we needed to address this issue.
Attachment and Biobehavioral Catch-up consists of 10 intervention sessions, each lasting one hour, which are delivered in mothers’ homes. The intervention helps mothers provide nurturing care even when children do not elicit it (Sessions 1–2) and even when they struggle to respond to their children’s distress with nurturance (Sessions 7–8). This program also increases mothers’ delight in their children through following their children’s lead (Sessions 3–4, 9), and helps mothers parent in non-threatening or frightening ways (Sessions 5–6).
Although the various sessions target different issues, the interventionist conceptualizes the most challenging issues for mothers after each session and addresses the most relevant issues indirectly or directly in other sessions as well. This is accomplished by carefully observing the mother–child interactions during the first few sessions. For example, if the parent trainer observes that a mother is adept at showing delight in her child, but struggles to respond sensitively, the intervention session may focus more on the importance of nurturing care even when the session emphasis is on following the lead.
The intervention is manualized. Although the content is provided in the manual, we expect interventionists to practice the intervention extensively prior to (p. 313) implementing such that they do not need to refer to the manual during their work with mothers.
Sessions 1–2: Providing nurturing care even when the child does not elicit nurturance. Mothers are introduced to the intervention through discussion of their beliefs about a number of aspects of mothering. Several myths of mothering, such as “Babies get spoiled if they get picked up,” are discussed, with some of the refuting evidence presented briefly.
Following the introduction, videos of babies who are easily soothed by their mothers are contrasted with videos of babies who either turn away from or are resistant to their mothers. Mothers are helped to see how challenging it is to provide nurturing care in the latter two instances, and yet how critical it is.
Sessions 3–4: Following the child’s lead with delight. Mothers see videos of other mother–child dyads in which the mother is following the child’s lead or taking the lead herself. She is asked to do several activities with her child, focusing on following the child’s lead, such as playing with a book with pull-out shapes, playing with blocks, or making pudding. The interventionist scaffolds the activities, pointing out times when the mother follows the lead, and making suggestions for other ways she might respond to the child. The interventionist particularly stresses the importance of taking delight in the child’s efforts.
Session 5–6: Interacting in non-frightening ways. Mothers are shown videos of other mothers who behave in intrusive or overwhelming ways, missing their children’s cues of feeling overwhelmed or fearful. Mothers are then asked to play with their children with puppets, but very carefully paying attention to children’s signals. Because playing with puppets often elicits intrusive behavior, it is intentionally presented so that mothers will have opportunities to think about how to avoid behaving in intrusive or frightening ways. Mothers are helped to recall times in their own histories when their caregivers were intrusive or frightening, and to recall their own reactions. Finally, mothers are supported in recognizing how they may behave in threatening ways themselves, acknowledging the effects of this behavior on their relationships with their children, and developing strategies for monitoring these frightening behaviors in future interactions.
Sessions 7–8: Voices from the past. Recognizing influences from the past that affect caregiving. Session 6 introduces the importance of mothers’ earlier experiences on their caregiving, and Sessions 7 and 8 deal with these issues more explicitly. Mothers are helped to think through experiences with their own caregivers that affect how they react to children’s bids for reassurance, and opportunities to follow children’s lead. They are helped to become conscious of the “voices from their past” that they hear when parenting.
In so doing, their parenting can become no longer automatic (i.e., driven by their own experiences), but rather consciously chosen. For example, although a mother may think to herself, “Oh, you’re such a whiner” when her child asks her to be held, she recognizes that this emanates from her own experiences of asking for reassurance when she was a child. She can then consider the most appropriate (and nurturing) way to respond, “overriding” her natural propensity to turn her child away. The work of Lieberman and colleagues was influential to our conceptualization of these issues (Lieberman, Padron, Van Horn, & Harris, 2005).
(p. 314) Sessions 9–10: Consolidating gains. Sessions 9 and 10 have specific content (encouraging mothers to hold their children more and encouraging mothers to help their children understand, and eventually express, emotions effectively, respectively). For example, mothers are encouraged to engage in a cuddling task with their child in Session 9. During Session 10, mothers are encouraged to “label” their child’s emotions throughout the session as a means of helping the child organize different feelings and affective states (Izard, Fine, Mostow, Trentacosta, & Campbell, 2002). However, the primary objective of these sessions is to continue the emphasis on mothers’ nurturing their children, following their children’s lead with delight, and behaving in non-frightening ways. Interventionists show videos that highlight the progress parents have made in each of the three areas, and celebrate their progress.
Why Intervene in Mothers’ Homes?
Although it takes more staff time to intervene in families’ homes than in a clinic or office, we consider it critical. Most especially, we want to maximize the likelihood that change in maternal behaviors will generalize to their natural, everyday environment. If mothers come into a clinic, they may well become more nurturing and follow their child’s lead better while they are in a session—but they might have difficulty transferring nurturing behavior to the home environment, where perhaps there are more demands and stress. We have intervened with a mother when there were as many as nine additional people in the living room. We find that helping the mother become nurturing, follow the child’s lead, and behave in a non-frightening fashion is a very different task when children and adults of different ages and with different needs are present, than if we were to simply intervene with the mother and the child referred for the program.
Why a 10-Session Brief Treatment Model?
There are several advantages to limiting the intervention length, even though we often find that there is still work to be done at the end of 10 sessions. There is a sense of urgency to reach the objectives within the allotted time frame. Interventionists keep in mind how many sessions they have to reach goals, and it provides a structure (as well as a deadline). When, for example, a mother is not following the lead by Session 6, the interventionist thinks of how to incorporate videos that will emphasize the importance in subsequent sessions—but keeping in mind how many sessions remain.
The focus of this intervention differs substantially from longer-term psychotherapy-oriented programs. By exploring their own attachment-related experiences and memories, we help mothers understand their propensities for frightening behavior, and their difficulties with delighting in their child or providing nurturing care. We do this in a supportive context that scaffolds their growth through positive feedback and celebrates their progress. Based on the limited time frame and targeted nature of this program, we place less emphasis on the processing of the mother’s mental and emotional state (i.e., feelings of shame, guilt, (p. 315) and anxiety about her parenting or substance abuse issues) during the treatment program, when compared with programs of longer duration. However, we are especially enthusiastic about our effectiveness in changing mothers’ behaviors and children’s outcomes given the short-term behavioral nature of this attachment-focused program.
What Techniques are most Important?
Perhaps the most important component of the intervention is providing “in the moment” feedback to mothers. The interventionist needs to keep in mind the intervention manual content while attending to ongoing interactions between the mother and child. For example, while explaining the importance of nurturance for young children, the interventionist is also attending to the interactions between the mother and child during the session. An interventionist may point out several of mother’s displays of nurturance and child’s response during the one-hour session. If the mother misses an opportunity to respond sensitively to her child, the interventionist may gently comment, “What do you think about your child’s behavior right now? He looks like he doesn’t want you, but I wonder what would happen if you rubbed his back anyway.”
We also find that it is extremely important to provide supportive, positive feedback to the mother. Even though the interventionist needs to be able to point out weaknesses, this can be accomplished much more readily in the context of a trusting relationship than otherwise. The interventionist needs to “catch the mother being good”—even in the context of the most problematic mothering, there are examples of the mother attending to the child, the child looking to the mother for reassurance, etc.—and is where the interventionist needs to start.
Empirical Evaluation of Abc for High-Risk Parents
The effectiveness of Attachment and Biobehavioral Catch-up among high-risk mothers has been assessed through a randomized clinical trial with 120 birth mothers, many of whom who use substances, and their young children. In this randomized clinical trial, mothers were randomly assigned to receive either the Attachment and Biobehavioral Catch-up intervention or a control intervention. The control intervention, called Developmental Education for Families (Ramey, McGinness, Cross, Collier, & Barrie-Blackley, 1982; Ramey, Yeates, & Short, 1984), targeted cognitive and language development and was selected because it contained the same number, duration, and structure of sessions but did not focus on improving the parent–child relationship quality.
Following the intervention, mothers participated with their children in the Strange Situation so that children’s attachment quality could be assessed. Salivary cortisol was assessed prior to and following the Strange Situation. Children whose mothers had received the ABC intervention showed secure attachment more frequently and disorganized attachment less frequently than children in the DEF intervention (Bernard, Bick, & Dozier, 2010). Furthermore, children from the DEF (p. 316) intervention showed cortisol reactivity in the Strange Situation, which was not seen among children in the ABC intervention (Bernard & Dozier, 2010). Cortisol reactivity is typically not seen among young children whose mothers buffer them effectively from stress. Taken together, these results support the effectiveness of the Attachment and Biobehavioral Catch-up intervention in helping children develop secure attachment behaviors and improved behavioral and biological regulation.
We find these preliminary results exciting in that they illustrate the potential for our program to improve parenting outcomes among substance-abusing parents. However, given that the sample of high-risk birth mothers included both substance-abusing and non-substance-abusing mothers at risk for neglect, we are aware of the need for future research. Many mothers with substance-abuse issues participated in drug treatment and relapse prevention programs alongside the ABC program. In recruiting mothers with substance-abuse problems, we found that some mothers had been involved in drug treatment programs for some time, whereas others had just initiated the drug treatment process. In our ongoing work, it seems necessary to address whether intervention effectiveness is associated with stage of recovery and involvement in drug treatment programs. Further, it seems important to explore whether child age and addiction type and severity might be associated with the degree to which mothers benefit from the ABC program. We expect that such questions will be important for delivering treatment programs with maximal effectiveness.
Conducting Research with Substance-using Mothers
There are many challenges to engaging substance-using mothers in an intervention program and associated research, such as their initial skepticism or lack of interest in participation in research, and difficulty in scheduling due to frequent moves and disconnected phone numbers. We have implemented a range of strategies for recruiting and retaining these mothers as participants in our research. Probably most critical to our research efforts is the relationship we develop with the families, such that mothers do not feel like research “subjects.” This begins with the initial phone call and is essential throughout the research visits and intervention sessions. In addition to research staff and interventionists’ responding to mothers with a warm and open manner, we encourage staff to bring framed photographs of mothers and their children from earlier visits, send Mother’s Day cards and gifts, and give children birthday presents at yearly follow-up visits. Additionally, we maintain as much consistency as possible concerning which staff members make phone calls and conduct follow-up visits. Although these efforts help in engaging mothers in the research, we often still have difficulty scheduling follow-up visits with these families due to frequent transitions in housing and changes in contact information. Thus, we have found it critical to obtain information for several emergency contacts and maintain frequent contact through phone calls and letters. Furthermore, we have several staff members who are racially and socio-economically similar to our mothers and familiar with the neighborhoods in which the mothers live. They are able to make connections with community members (p. 317) and more easily track difficult-to-reach participants. Although substance-using mothers are challenging to work with for these reasons, we have found working with them to be incredibly rewarding.
Attachment and Biobehavioral Catch-up was developed as an intervention to enhance parenting among high-risk mothers and their young children. The intervention focuses on several issues that have been found to be problems among substance-using mothers. Although the intervention does not address substance use specifically, we think that enhancing mothers’ motivation to parent effectively and helping parenting become a more rewarding endeavor serves as a strong motivator for reducing substance use. This intervention has been shown effective in changing children’s ability to trust in their mothers and in their ability to regulate physiology in a randomized controlled study.
Support for this research was provided by NIMH R01 awards 052135, 074374, and 084135 to the first author. We acknowledge the support of the Delaware Division of Family Services and the Philadelphia Department of Human Services; and caseworkers, foster families, birth families, and children at both agencies.
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