A NEW START FOR MOMS. Linda Gertson, Ph.D., Kayleigh Hunnicutt, Samuel Ballou, Edward Guiterrez, Keighlynn Adlof and Juanita Bigheart.

Transcription

1 August 2017 A NEW START FOR MOMS Effects of adverse childhood experiences on adult psychopathology and response to integration of mental health and substance abuse treatment services with a perinatal treatment population Linda Gertson, Ph.D., Kayleigh Hunnicutt, Samuel Ballou, Edward Guiterrez, Keighlynn Adlof and Juanita Bigheart

2 A New Start fo Moms (ANSFM) Program description: State ADP Licensed Outpatient Drug Free Program State Certified Drug MediCal Site State Certified Day Care Rehabilitative Program 2

3 ANSFM Target Presentation Pregnant and substance using; or Parenting and substance using, with a child(ren) ages birth through 17. Parenting also includes a woman who is attempting to regain legal custody of her child(ren). Priority admission: Pregnant injection drug users; Pregnant substance users; Parenting injection drug users; and Parenting substance users. 3

4 ANSFM Program Services Program Services include: Assessment Perinatal Program using group modality Methamphetamine Track Court Mandated Track Crisis Intervention 4

5 ANSFM Program Services Basic health screening & women s care Parenting education On-site child watch HIV education & STD education class Perinatal education Referrals to other helpful resources Transportation Public Health Nursing available On-site drug testing 5

6 ANSFM Study It was hypothesized that the ANSFM program would be enhanced by the inclusion of mental health services. The rationale for the study was based on the following: Decisions regarding services should be driven by empirical data. Empirical studies indicate that approximately 70% of substance abusing women have histories of trauma. Evidenced-based practices, such as Integrated Dual Diagnosis Treatment (IDDT), have proven the superiority of integrated mental health and substance abuse treatment for individuals with co-occurring substance use and psychiatric disorders. 6

7 ANSFM Study The ANSFM study was designed with the following intentions: To assess number of Adverse Childhood Experiences (ACE) reported by subjects and compare with ACE data from the original study conducted by Kaiser and the Centers for Disease Control. To compare childhood adverse experiences with adverse experiences in adulthood (in the same client). To compare reduction of anxiety and depression symptoms for clients receiving ADP only services with those receiving both ADP and mental health services (psychosocial assessment and individual psychotherapy). To examine factors related to relapse to substance abuse. To use study results for program improvement. 7

8 Adverse Childhood Experiences (ACE) Scale The original ACE study conducted in 1995 and 1996 was based at Kaiser Permanente s San Diego Health Appraisal Center and conducted in collaboration with the Centers for Disease Control. The ACE scale is a 10-item measure that assesses various types of traumatic experiences before the age of 18. The results of the ACE responses were compared with the patients medical records to ascertain whether there is a relationship between early adverse events and adult health. 8

9 Adverse Childhood Experiences (ACE) Scale ACE contents: Three categories of childhood abuse: psychological abuse, physical abuse and contact sexual abuse Four categories of exposure to household dysfunction during childhood: exposure to substance abuse, mental illness, violent treatment of mother or stepmother, and criminal behavior. 9

10 Adverse Childhood Experiences (ACE) Scale ACE Related Health Problems include: Alcoholism/Drug Dependence Depression Suicide Attempts Smoking High Risk Sexual Behavior Poor Health Related Quality of Life Chronic Obstructive Pulmonary Disease Obesity Fetal Death Ischemic Heart Disease Liver Disease, Cancers Intimate Partner Violence 10

11 The ACE Pyramid 11

12 ANSFM STUDY BACKGROUND: Effects of Childhood Maltreatment Adverse Childhood Experiences (ACE) (Felitti, et al., Anda, et al., 2006) Compared to individuals who had no exposure to adverse childhood experiences, those with exposure to four or more categories had a 4 to 12-fold increased for alcoholism, drug abuse, and depression. For persons with 4 or more ACEs, the risk of smoking, alcoholism, illicit drug use, and injection drug use were increased 1.8, 7.2, 4.5 and 11.1, respectively. For persons with 4 or more ACEs, the risk of early intercourse, promiscuity, and sexual dissatisfaction were increased 6.6, 3.6, and 2-fold, respectively. 12

13 Effects of Childhood Maltreatment Women who reported four or more types of abuse were 1.5 times more likely to have an unintended pregnancy at or before the age of 20. Farrugia (2011) found that individuals who experienced childhood trauma had a significantly earlier age of intoxication and had used significantly more drug classes in their lifetime than those with no experience of childhood trauma. Dietz, et al. (2011) and Hillis, et al. (2011) found a strong doseresponse link between number of childhood adverse experiences and adolescent pregnancy. Abuse or household dysfunction may influence a woman s feelings of control or power in sexual relationships and may lead to difficulty in negotiating contraceptive use with a partner (Dietz, et al., 2011, p. 1363). 13

14 Effects of Childhood Maltreatment Teicher and Samson (2013) found that maltreated individuals with depression, anxiety and substance use disorder had an earlier age of onset, greater symptom severity, more comorbidity, and increased risk for suicide and poorer treatment response than individuals without a history of childhood maltreatment. These authors propose that individuals with childhood maltreatment constitute a critically distinct subtype of depressive, anxiety and substance use disorders and recommend adding the specifier With Maltreatment History or With Early Life Stress to Axis I disorders. 14

15 Consequences of Childhood Neglect According to the National Scientific Council on the Developing Child, severe neglect appears to be an even greater threat to health and development as physical abuse including more cognitive impairments, language deficits, academic problems and deficits in peer interaction. Hildyard and Wolfe (2002) report that neglect is the most common form of childhood maltreatment and often involves chronic situations that are not as easily identifiable as specific incidents of abuse. They found that children who experience neglect demonstrate more severe cognitive and academic deficits, social withdrawal and limited peer interactions. They conclude that there is a lack of sufficient research on the long-term consequences of neglect. 15

16 Consequences of Childhood Neglect Spertus, et al. (2003) conclude Emotional abuse and neglect may be powerful predictors of adult emotional functioning that should not be overlooked due to the more subtle nature of this form of trauma (p. 1257). DeBellis (2005) suggests that child neglect may activate biological stress response systems contributing to adverse brain, cognitive and psychobiological development. This adverse development may be manifested in delays or deficits of behavioral and emotional regulation, cognitive and psychosocial function, antisocial behaviors and poor academic achievement. 16

17 Consequences of Childhood Neglect Widom, Czaja and Dutton (2008) found that all types of childhood victimization were associated with increased risk for lifetime re-victimization, particularly risk for interpersonal violence. However, the neglect only group and those who experienced multiple forms of childhood abuse and neglect experienced higher numbers of lifetime traumas and victimization experiences. The authors point out that while the literature does not often attend to revictimization risk for neglected children, the findings of their study suggest that their risks are substantial. 17

18 Consequences of Childhood Neglect Norman, Byambaa, De, Butchart, Scott and Vos (2012) conducted a systematic review and meta-analysis on the long-term consequences of child physical abuse, emotional abuse and neglect. This overview of evidence suggested a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behavior. The authors refer to the emerging evidence that neglect in childhood may be as harmful as physical and emotional abuse. 18

19 Consequences of Childhood Neglect Putnam-Hornstein, Cederbaum, King, Eastman and Trickett (2015) found that a maternal history of maltreatment emerged as the strongest predictor of both reported and substantiated offspring maltreatment by age 5 years, even after adjustment for other socio-demographic risk factors. The authors concluded, Future research should explore intergenerational dynamics that may operate via maternal exposures to different types of maltreatment (e.g., neglect, physical abuse, sexual abuse) and examine mediating pathways between maternal maltreatment and abuse or neglect in the next generation (e.g., substance use) (p. 502). 19

20 Consequences of Childhood Neglect Hanson, Hariri and Williamson (2015) suggest that emotional neglect is prevalent but often goes unreported and is one of the most predictively potent maltreatment types associated with symptoms of Major Depressive Disorder as well as psychological difficulties such as shame, humiliation, anger, feelings of worthlessness and poor emotion regulation. 20

21 Consequences of Childhood Neglect Taillieu, Brownridge, Sareen and Afifi (2016) utilized the results of the ACE and results from a nationally representative adult sample from the United States. They found that experiencing both emotional abuse and emotional neglect during childhood increased the odds of adult major depression, dysthymia, mania, any mood disorder, panic disorder, social phobia, generalized anxiety, and PTSD. Emotional neglect was also associated with borderline and avoidant personality disorders. 21

22 Consequences of Childhood Neglect Taillieu, et al. (2016) concluded that lack of love, affection, and support that characterizes emotional neglect likely compromises a child s ability to form a secure attachment with caregivers which is hypothesized to provide the foundation for later individual differences in personality development and psychopathology (p. 12). 22

23 Consequences of Childhood Neglect Alvarez-Alonso, et al. (2016) studied the association between maltreatment and polydrug use among adolescents. They found that polydrug users had a greater prevalence of all types of maltreatment, but especially sexual abuse and emotional neglect. Other relevant variables were the presence of depressive and/or anxiety disorders and the family history of alcohol dependence. 23

24 Consequences of Childhood Neglect In the 2017 issues of the International Journal of Child Abuse & Neglect there are multiple publications which are very similar to the study being conducted at ANSFM indicating that our research is extremely contemporary and in the mainstream of the associated body of literature: Cohen, Menon, Shorey, Le and Temple (2017) found that early neglect poses a risk for the development of internalizing symptoms and substance use behaviors among emerging adults. The authors suggest that further research should be conducted to determine whether mental health differences exist between neglect subtypes. 24

25 Consequences of Childhood Neglect Cecil, Viding, Fearon, Glaser and McCrory (2017) found that emotional abuse emerged as the only maltreatment type to uniquely contribute to internalizing difficulties as well as trauma-related symptomatology. They suggest that the effects of emotional abuse require greater attention in research, policy and clinical practice. The implementation of intervention strategies designed to foster parental warmth, parenting skills and positive parent-child interactions may be particularly effective in counteracting the consequences of emotional abuse and preventing future experience of victimization (p. 117). 25

26 Consequences of Childhood Neglect Bartlett, Kotake, Fauth and Easterbrooks (2017) found that intergenerational rates of maltreatment were highest for typeto-type transmission (for example, neglect of children was >60% more likely when their mothers had neglect histories). They further found that there was a 300% increase in multiple-type maltreatment when mothers experienced multiple-type maltreatment during their own childhoods. The authors conclude that screening with attention to types of abuse and neglect that mothers may have experienced during childhood will inform a more nuanced understanding of child maltreatment prevention among mothers with histories of abuse and neglect (p. 93). 26

27 Consequences of Childhood Neglect Li, Long, Cao and Cao (2017) conducted a longitudinal study to examine the links between each type and accumulative types of childhood maltreatment (CM) women experienced and maternal depression risk throughout the perinatal period. The study found that physical and emotional neglect and two or more types of maternal CM were related with higher overall depressive symptoms throughout the perinatal period. No significant effects of other types of maternal CM or one type of maternal CM on perinatal depressive symptoms were detected. The authors conclude that their findings may have significant implications for future investigations to examine the effects of childhood neglect in maternal mental health. 27

28 Consequences of Childhood Neglect Briere, Runtz, Eadie, Bigras and Godbout (2017) hypothesized whether the effects of disengaged parenting (DP) would predict adult psychological symptoms even more than childhood sexual, physical of psychological abuse. They found significant indirect effects of DP on psychological symptoms through sexual and nonsexual abuse, as well as through attachment. The authors suggest that exposure to DP may be especially detrimental, both by increasing the risk of child abuse and via the impacts on insecure attachment. They support the use of attachmentoriented intervention in the treatment of adults maltreated as children. 28

29 Drugs of Choice Use Among ANSFM Clients (Cal OMS Data) 15/16 16/17 (to date) PRIMARY DOC Meth 69% PRIMARY DOC Meth 54% Alcohol 13% Alcohol 10% Marijuana 8% Marijuana 11% Heroin 10% Heroin 19% SECONDARY Meth 13% SECONDARY Meth 22% Alcohol 16% Alcohol 12% Marijuana 17% Marijuana 22% Heroin 5% Heroin 3% None 43% None 37% 29

30 Substance Use Among ANSFM Mental Health Clients Attention must be called to the stark rise in heroin as the reported primary drug of choice (Year 15/16, 10%; Year 16/17, 19%). Changes in percentages for others drugs (primary and secondary) are not as substantial. Although 69 percent (15/16) and 54 percent (16/17)of these clients report current drug of choice as methamphetamine: 35 percent (15/16) and 50 percent (16/17) report that MJ was first drug used Average age of onset for MJ for both cohorts is 14 years. 30

31 Psychiatric Diagnoses Among ANSFM Mental Health Clients The majority of the clients in the study population had either an anxiety disorder, a depressive disorder or a combination of both anxiety and depression. The most prevalent disorders were: Posttraumatic Stress Disorder (40%) Generalized Anxiety Disorder (23%) Dysthymia (19%) Major Depressive Disorder (17%) Panic Disorder (15%) Combination of an anxiety disorder and a depressive disorder (26%) 31

32 Children of ANSFM Mental Health Clients Average Number of Children: 3 (Range 1 to 12 children) 75 percent of the women have lost custody of their children. The majority of the children are placed with extended family members. 32

33 ANSFM Study Instruments The ANSFM study looked at data collected from July 2015 through May The clients were assessed via the following instruments: The Adverse Childhood Experiences (ACE) Scale The Adult Adverse Experiences Scale (AAE). This scale was developed through modification of the World Health Organization s International Violence Against Women Survey (IVAWS) to create domains which matched those of the ACE. The intent was to compare type-to-type adverse experiences across the lifetime of the study participants. 33

34 ANSFM Study Instruments The Beck Depression Inventory The Beck Anxiety Inventory The Becks were administered at baseline and every 30 days afterward. The Relapse Factor Scale This instrument asked the clients to indicate which factors were related to their most recent relapse to substance use. This scale consists of 40 different factors across 7 domains. The domains are: Struggling with Emotions; Interpersonal Relationships; Hardship; Cue-Induced; Substance Use of Others; Victimization; and Medication-Related. 34

35 Comparison of Prevalence of Individual Adverse Childhood Experiences (women only) ACE Category Abuse Neglect Household Dysfunction Original Kaiser ACE Study ANSFM ACE Study Emotional Abuse 13.1% 50.0% Physical Abuse 27.0% 39.0% Sexual Abuse 24.7% 48.7% Emotional Neglect 16.7% 57.3% Physical Neglect 9.2% 23.1% Mother Treated Violently 13.7% 35.3% Household Substance Abuse 29.5% 58.5% Household Mental Illness 23.3% 36.5% Parental Separation or Divorce 24.5% 64.6% Incarcerated Household Member 5.2% 24.3% 35

36 ACE Categories: Emotional Abuse/Neglect Emotional Abuse: Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physical hurt? Emotional Neglect: Did you often or very often feel that no one in your family loved you or thought you were important or special? OR Your family didn t look out for each other, feel close to each other, or support each other? 36

37 ACE Score Comparisons 70% 60% 50% Comparison of ACE Scores Kaiser and ANSFM 61% 40% 35% 30% 20% 10% 0% 25% 15% 16% 15% 10% 10% 11% 4% or more Kaiser ACE Study ANSFM ACE Study 37

38 Results ACE Scores The Adverse Childhood Experiences inventory consists of 10 domains of adverse experiences. 61% of our clients endorsed a total ACE score of 4 or higher. Percentage Endorsed 18% 16% 14% 12% 10% 8% 6% 4% 2% 4% 15% 10% 11% 13% 16% 9% 7% 9% 5% 2% 0% Total ACE Score 38

39 Adult Adverse Experiences Results Category Percent Emotional Abuse 87.6% Physical Abuse 83.9% Sexual Abuse 49.3% Household Substance Abuse Household Mental Illness 86.4% 58.0% Separation/Divorce 28.3% Incarceration Lived with anyone who has been to prison 53.0% Lived with anyone who has been to jail 91.3% 39

40 Results AAE Scores Percentage Endorsed The Adult Adverse Experiences (AAE) questionnaire consists of 7 domains of adverse experiences. 85% of our clients endorsed a total AAE score of 4 domains or higher. 35% 30% 25% 20% 15% 10% 5% 0% 2% 2% 2% 7% 17% 26% 31% Total AAE Score 11% 40

41 Comparisons Between Adverse Childhood Experiences & Adult Adverse Experiences Childhood Emotional Abuse/Neglect Childhood Emotional Abuse/Neglect Childhood Emotional Abuse/Neglect Adult Emotional Abuse 93% Adult Physical Abuse 89% Adult Sexual Abuse 56% Childhood Physical Abuse Adult Physical Abuse 58% Childhood Physical Abuse Adult Sexual Abuse 63% Childhood Sexual Abuse Adult Sexual Abuse 60% Childhood Sexual Abuse Adult Physical Abuse 83% 41

42 Summary Points for Abuse-Related Data As shown in the preceding table, Childhood Emotional Abuse and Neglect have high correlations with adult adverse experiences, particularly Adult Emotional Abuse, indicating the importance of attention to this form of childhood maltreatment and it s impact on adult interpersonal relationships. 42

43 Summary Points for Abuse-Related Data The results of the ANSFM study are consistent with those of Cecil, et al. (2017) reported above which found a unique contribution of emotional abuse to adult symptomatology and the need for greater attention to this form of childhood maltreatment in research, policy and clinical practice. In addition, the ANSFM study results support the suggestion by Bartlett, et al. (2017) for attending to types of childhood abuse and neglect experienced by mothers and their conclusion that attention to types of abuse could result in an enhanced approach to prevention of trans-generational abuse. 43

44 Beck Data Clients were given the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) at Orientation, and then at every 30 days post-intake to ADP. Clients who elected to also receive mental health services (ADP+MH clients) were administered the Beck inventories approximately the same time frames as those who elected to not receive MH services (ADP Only clients). Client scores were examined by 30 day intervals, as well as comparing baseline to final follow-up scores, for clients who had follow-up data. 44

45 Orientation Beck Scores Analysis of clients orientation Beck scores revealed differences between the following groups of clients: 1. Orientation Only: Those who attend orientation only 2. ADP Only: Those who participate in ADP treatment but do not receive MH services 3. ADP+MH: Clients who receive both ADP and MH services In particular, Orientation Only clients have Beck Depression Inventory and Beck Anxiety Scale scores similar to ADP+MH clients. It should be noted that approximately 40 percent of the clients fit into the category of Orientation Only indicating the difficulty of engaging this population into treatment. This data suggests that additional outreach efforts should be made to engage these clients in treatment. 45

46 Beck Data Comparisons BDI Scores BDI Orientation Data Comparisons Orientation Only ADP Only ADP + MH 46

47 Beck Data Comparisons BAI Orientation Data Comparisons BAS Scores Orientation Only ADP Only ADP + MH 47

48 Beck Data Summary ADP+MH have higher scores on the BDI and the BAI at orientation than ADP Only clients. This data suggests that clients with more severe symptoms are engaging in mental health services either as the result of self-referral or ADP counselor referral. Clients who receive ADP+MH services appear to experience a greater reduction in symptoms compared to ADP only. Longer duration in MH treatment appears to be predictive of larger reductions in Beck scores. 48

49 Beck Data Comparisons BDI Scores Overtime 16 BDI Scores Orientation Follow Up 1 Follow Up 2 Follow Up 3 ADP Only ADP + MH 49

50 Beck Data Comparisons BAI Scores Overtime BAS Scores Orientation Follow Up 1 Follow Up 2 Follow Up 3 ADP Only ADP + MH 50

51 Completion Status (CalOMS Data) Completion Status ADP ONLY ADP+MH Completed Treatment 19% 42% Left Before Completion (Satisfactory Progress) 32% 35% Left Before Completion (Unsatisfactory Progress) 46% 23% 51

52 Relapse Factors During orientation the clients are administered a Relapse Scale. This scale consists of 40 different factors across 7 domains. The domains are: Struggling with Emotions; Interpersonal Relationships; Hardship; Cue-Induced; Substance Use of Others; Victimization; and Medication-Related. The clients are asked to endorse which factor(s) contributed to their most recent relapse. The following slides describe the Relapse Factors most frequently endorsed by clients receiving mental health and alcohol/drug services, clients receiving only alcohol/drug services and clients who did not continue services following orientation. 52

53 Relapse Factors 70% 60% 50% 40% 30% 58% Top Five Relapse Factors Reported by Clients 61% 56% 53% 52% 51% 47% 44% 44% 43% 44% 44% 39% 37% 33% 20% 10% 0% Struggling with Emotions Homeless Relationship Conflict Family Conflict Family Crisis Orientation Only ADP Only ADP + MH 53

54 Relapse Factors Other Frequently Endorsed Relapse Factors 40% 35% 30% 25% 20% 15% 10% 5% 0% Orientation Only ADP Only ADP + MH 54

55 Relapse Factors Summary As the data indicates, clients who participate in the ANSFM program predominantly endorse relapse factors related to emotional problems, interpersonal conflict and homelessness. Clients who request and/or are referred for mental health services appear to be particularly vulnerable to these relapse factors. This finding supports the recognition that symptoms of psychiatric dysfunction (i.e., struggling with emotions) frequently co-occur with substance use disorders and the necessity of including mental health services as part of the treatment regimen offered through ANSFM. 55

56 Relapse Factors Summary The stress of homelessness is also a distinct risk for relapse in this population. Homelessness for ANSFM clients includes unstable housing such as residence in recovery homes and fluctuation among various family members or friends. Contact with other substance abusers was also endorsed as an experience which contributed to relapse. Taken together the results of this analysis support the concept of stress-induced and cue-induced craving as common risk factors for relapse to substance use. 56

57 What This Study Did Not Find There is a fairly long history of studies attempting to ascertain whether there is a relationship between specific psychiatric disorders and drug(s) of choice. This study did not reveal any such correlation. The study of this particular population suggested that drug of choice appears to be more directly related to availability of the substance in the community and/or the substance used by partners, friends or other relationships. This finding should not be assumed to be definitive or to negate the results of any other studies which have found a relationship between psychiatric disorders and drug use. 57

58 Discussion This study found a high endorsement of emotional abuse and emotional neglect as early adverse childhood experiences, even greater than sexual or physical abuse. The study also found a significant correlation between these particular adverse experiences with emotional abuse experienced in adulthood. These results suggest that deprivation of positive attachment experiences in childhood may be directly related to the ability to form mutually nurturant experiences in adult relationships. 58

59 Discussion The endorsement of factors related to interpersonal conflict as a contribution to substance use relapse suggests that this deficit in forming positive interpersonal relationships may impair resistance to relapse to substance use. Taken together, the findings of this study suggest the importance of exploring the client s history of abusive experiences during childhood ( biographical narrative ) as well as how these experiences are impacting present interpersonal behaviors. Clinicians should consider inclusion of the biographical narrative when implementing tools such as cognitive behavioral therapy (CBT), EMDR, etc. during the course of treatment. 59

60 Discussion The results of the ANSFM study support findings of the previous body of literature described in the background section of this presentation regarding the prevalence of childhood emotional maltreatment, i.e. emotional neglect and emotional abuse, as common forms of childhood maltreatment. Results of the present study also clearly support the previous research which describes the correlation between adverse childhood experiences and adult dysfunction, including deficits in emotion regulation, psychosocial functioning, interpersonal conflict, difficulty setting appropriate boundaries with others, substance dependence and comorbid psychiatric pathology, particularly anxiety and depressive disorders. 60

61 Discussion This is the first study which attempted to draw a correlation among the following variables: specific domains of childhood adverse experiences with those of specific adult adverse events; the association with adult co-occurring psychiatric symptoms and substance abuse; and an analysis of factors which increase potential for alcohol/drug relapse. Contemporary research suggests that early adverse experiences results in a cascade of biological and psychological consequences which contribute to deficits in self-regulation, inability to form healthy attachments, poor coping strategies, early onset of substance abuse, adult pathology including psychiatric and substance use disorders and risk for relapse. These deficits can have a negative impact on parental behavior and contribute to transgenerational abuse and neglect. The current study supports this hypothesis as illustrated in the following slide. 61

62 Discussion Childhood Emotional Abuse/ Neglect Relapse to Substance Use / Dependence Early Onset of Substance Use Deficits in Ability to Cope with Interpersonal Conflict Continuation of Adverse Experiences/ Victimization Psychiatric Disorders (particularly depressive and/or anxiety disorders) Adult Substance Abuse / Dependence 62

63 Discussion The results of this study strongly suggest that PREVENTION and EARLY INTERVENTION are critical to reduce the cycle of maladaptive behavior described above. Since the clients in ANSFM are adults and have histories of both childhood and adult adverse experiences, we cannot undo the past but can add interventions that may ameliorate the impact of the past while enhancing their abilities to achieve and sustain abstinence from drugs/alcohol, cope with negative emotions and improve reaction to interpersonal conflict. It is likely that the clients personal histories of emotional abuse and neglect impairs healthy bonding with their own children. The addition of program elements to improve mother/child interaction could increase the ability of the women to form secure attachments with their children. It is hoped that these changes would result in an improvement in the early environment of the offspring and decrease the risk that the offspring would follow the same pattern as the ANSFM moms. 63

64 Suggestions Based on the results of this study, we made the following suggestions for ANSFM program improvement and additional data elements: Additional outreach to clients who discontinue services after orientation or intake Enhancement of therapeutic interventions to increase clients ability to cope with interpersonal conflict In agreement with the studies of Cecil, et al. and Briere, et al. we support the inclusion of a program (such as reflective parenting ) to enhance clients ability to form secure attachments with their children and prevent transgenerational abuse/neglect. ANSFM is currently planning to arrange for staff training in this intervention with the intent of adding this component to the curriculum. 64