Substance Dependent Women: Mental Disorder and Representations of Their Young Children

Background. Parents who misuse drugs are at risk for problematic parenting, including referral to the child welfare system. Many therapeutic interventions for high-risk parents focus on repairing and reframing the representations parents have of their children (e.g., Lieberman, 1997). Yet little is known about representations substance-misusing women hold of their children and whether those representations are related to other risk factors in their lives. The goal of this paper is to examine whether representations substance-dependent women have of their young children are associated with mothers' concurrent mental health problems.

Methods. One hundred and fifty urban African-American women in methadone treatment for heroin dependence participated in the study. All had primary custody of a 3-to-5-year-old child. Women were interviewed using the Structured Clinical Interview for DSM-IV (SCID) (Spitzer et al, 1992), and axis I and II diagnoses were made by two psychologists. 29% of women had a current mood disorder (e.g., major depression, dysthymia), and 19% had a cluster B personality disorder (e.g., antisocial personality disorder, borderline personality disorder). Women were also interviewed using the Working Model of the Child Interview (WMCI) (Zeanah, Benoit, and Barton, 1986), an hour-long semi-structured interview that asks about the mother's experiences with and perceptions of her child and her emotional response to her child. Transcribed interviews were coded by two reliable coders into three representation typologies (balanced, disengaged, or distorted) and were rated on Likert scales for multiple qualitative features and emotional tones in the narratives.

Results. These opioid-dependent mothers were at high-risk for problematic representations of their children compared to low-risk samples. 42% were coded as having disengaged representations of their children, 38% distorted, and only 20% balanced. A multinomial logistic regression analysis was computed with the three representational typologies as the dependent variable and the two mother diagnostic categories as the independent variables. Maternal depression was related to increased risk for distorted representations on the WMCI (odds ratio=3.2). Distorted representations are those in which the mother appears bewildered/confused, distracted, self-involved, or role reversing. Cluster B personality disorders were unrelated to representation category.

Multiple regression analyses were calculated on each of the rating scale outcomes with the two diagnosis categories as dichotomous predictors. Mothers with affective disorders and cluster B personality disorders both were more likely than other mothers to have representations of their children as difficult. Women's affective tone in describing their children was different depending on the type of mental disorder the mother was experiencing. Depressed mothers expressed more internalizing emotion – guilt and fear, and mothers with cluster B personality disorders expressed more externalizing emotion – anger.

Conclusions and Implications. Substance-misusing mothers with depression and those with personality disorders were at risk for perceiving their children as difficult and would likely benefit from parenting interventions that help parents reframe their perceptions of child behavior. Interventions, however, need to be sensitive to the differing emotional states of the parents being supported. Study findings also suggest the importance of integrating mental health services and parenting interventions within substance abuse treatment settings for women.