Exploring Relationships Among Trauma, Substance Misuse, and Attachment for Pregnant Women with Substance Use Disorders

BACKGROUND AND PURPOSE: Substance misuse during pregnancy and postpartum is an alarming public health problem resulting in significant maternal and child health inequities and child developmental risks (SAMHSA, 2017). Mothers with opioid and/or substance use disorder (OUD/SUD) often have histories of trauma, mental health disorders and insecure attachment styles, potentially affecting parenting practices (Kaltenbach, 2013) and intergenerational transmission of attachment difficulties (Salo & Flykt, 2013). Although some have found relationships between insecure attachment and substance misuse (Schindler, 2019), research is needed to understand the nuances within specific populations with SUD, such as pregnant and parenting women with severe trauma, in order to further develop targets for social work intervention. This study uses baseline data from an ongoing RCT of a therapeutic parenting intervention for mothers with OUD/SUD and their infants to explore the relationships among SUDs, trauma, mental health, and attachment.

METHODS: The Growing Together study is a 15-month, two-armed pragmatic randomized controlled trial for pregnant/parenting women with OUD/SUD and their infants. The two arms include: 1) BRIGHT, an attachment-based and trauma-informed parenting intervention; and 2) STAR, enhanced TAU. Participants are enrolled as early as the 24^th week of pregnancy and assessment sessions (conducted at baseline [pregnancy], 6 weeks, 6 months and 9 months postpartum) consist of qualitative interviews and quantitative questionnaires. Relevant baseline measures used for this study include the Adult Attachment Scale (AAS), Addiction Severity Index (ASI), Life Stressor Checklist (LSC-R), PTSD Checklist (PCL) and Brief Symptom Inventory (BSI), among others. Bivariate analyses were computed to explore preliminary relationships among variables with a specific focus on SUDs, trauma, mental health, and attachment.

RESULTS: The sample of 39 pregnant women (M age=31 years, SD=4.4; M week of pregnancy= 31.6 weeks, SD=4.5) were predominantly White (87%) and unmarried (69%); approximately half (46%) had completed high school, 1/3 (33%) completed some college, and most had prior child welfare involvement (69%); 80% were unemployed and 69% had incomes under $20,000. All had histories of opioid/substance misuse, extensive life traumas (M=16), with 56% at-risk for PTSD, and 77% had insecure attachment styles. Preliminary results, controlling for participant age, showed that number of lifetime traumatic events was significantly correlated with mental health challenges (r=.42, p=.008**) and secure attachment style (r= -.43, p=.02*). Trauma symptoms were also significantly correlated with secure attachment style (-.56, p=.001**) and marginally correlated with years of heroin (r=.28, p=. 09^t) and cannabis use (r=.31, p=.07^t). Overall, mental health challenges were significantly correlated with secure attachment style (r= -.54, p=.002**) and with years of heroin (r=.38, p=.02*) and cannabis use (r=.36, p=.03*).

CONCLUSIONS AND IMPLICATIONS: Results demonstrated that trauma history and symptoms are directly but differentially associated with substance use, attachment and mental health challenges for pregnant women. Attachment style was not directly associated with years of substance use; severity of trauma may be underlying attachment difficulties. Further research with a larger sample should investigate these associations as they have important implications for social work interventions with pregnant and postpartum women and infants.