Promoting Healthy Mother-Child Relationships: A Pragmatic Clinical Trial for Women in Opioid Use Recovery and Their Infants

Background:

In recent years, opioid misuse during pregnancy has become an increasing public health crisis in the United States. Pregnant and postpartum women managing an opioid use disorder (OUD) while parenting infants and young children are at heightened risk of many difficulties including maternal mental health challenges and impaired parental reflective functioning (Austin & Short, 2020; Rogers et al., 2021), leading to greater possibilities of compromised parenting, parent-child attachment relationships, and child behavioral and developmental outcomes in the long-term (Mirick & Steenrod, 2016; Peisch et al., 2018). Therefore, it is imperative to provide effective therapeutic interventions to support parents with OUD and their infants (Paris, et al., 2018). This study sought to assess the effectiveness of a home-based attachment-focused dyadic intervention, BRIGHT, through a community-engaged pragmatic randomized clinical trial. Aims included testing outcomes in the following domains among pregnant and postpartum women with OUD and their infants: 1) the parent-child relationship, 2) parenting capacities (including parenting stress and parental reflective functioning) and 3) maternal mental health.

Methods:

The study was conducted collaboratively with a prenatal wrap-around clinic for pregnant people with OUD. Fifty-seven pregnant women (M age=31 years; white = 83%; HS/some college=70%; income < $10,000=51%; never married=74%; housing insecure= 59%; at-risk of PTSD=51%; history of heroin/opioid use=93%; history of child welfare = 67%; parental reflective functioning, M=3.2) were recruited during the third trimester of pregnancy between January 2019 and January 2022 to participate in the 12-month pragmatic clinical trial. Participants were assigned to the BRIGHT treatment group (N=35) or the TAU+ control group (N=22) during randomization. Treatment group participants received up to 9-months of the weekly dyadic therapeutic parenting intervention whereas those in the control group received standard-of-care, referrals, and child development handouts. All participants were assessed at 4 different timepoints from third trimester of pregnancy to 9-months postpartum using a mix of standardized self-report measures, parent-infant videos, and interviews.

Results:

Results of the mixed-effects modeling demonstrated that BRIGHT had significant impact on improving the quality of parent-child relationships among parent-infant participants in the treatment group, as compared to the control group. Specifically, BRIGHT participants exhibited better outcomes concerning maternal withdrawal (F=8.22, p=0.0079), maternal intrusiveness (F=4.21, p=0.0501), infant negative affect (F=7.64, p=0.0101), and dyadic reciprocity (F=4.30, p=0.0474). Participants in both the treatment and control groups showed improvements in maternal mental health, reductions in parenting stress, and enhancements in parental reflective functioning over time.

Conclusions & Implications:

Although the sample size was small, the BRIGHT intervention demonstrated potential to enhance essential aspects of parent-child interactions for postpartum women with OUD and their infants. As the parent-child relationship is central to optimal child development, these findings are substantively meaningful. Given improvements of both groups in maternal mental health, parenting stress and parental reflective functioning, the specialty clinic standard services may be contributing to these changes along with BRIGHT. Future studies should strive to tease out effective mechanisms of change and augment attachment-based interventions with specific techniques, such as in-vivo dyadic infant-parent work, to support parents with OUD and their young children.