A randomized controlled trial and economic evaluation of the parents under pressure program for parents in substance abuse treatment.
Barlow J., Sembi S., Parsons H., Kim S., Petrou S., Harnett P. & Dawe S. (2019) Drug and Alcohol Dependence, 194: 184-194. doi: 10.1016/j.drugalcdep.2018.08.044. 

Is an intensive parenting programme effective at reducing child abuse potential in parents engaged in community drug and alcohol services?

This multi-center randomized controlled trial compared an intensive one-to-one parenting programme (Parents under Pressure, PuP) for primary caregivers of children under 2.5, engaged with community substance misuse services, with treatment as usual (TAU) in the UK. A sample of 100 parents was randomized to receive PuP (n=48) or TAU (n=52). Outcomes were measured at baseline, 6 and 12 months. The primary outcome of child abuse potential, measured using the Brief Child Abuse Potential Inventory (BCAP), was significantly improved in parents receiving PuP while those in TAU showed a deterioration. Significant reliable change was observed in 30.6% of the PuP group compared with 10.3% of the TAU group, and deterioration in 3% compared to 18%. Secondary outcomes assessed parental emotional regulation, psychopathology, and parenting stress using a range of measures. Intent-to-treat analysis found a significant improvement in emotional regulation for parents receiving PuP compared to TAU, and there was a trend towards a significant improvement in depression, anxiety, and stress. No statistically significant improvement in parenting stress was found. Probability of cost-effectiveness was approximately 51.8%-98.0%, depending on the cost-effectiveness threshold used. 

Commentary: 

There is a vast amount of evidence to suggest that the quality of the caregiving relationship is impacted by parental substance misuse. We also know that adverse outcomes, as a result of a poor parent-child relationship impacting on the developing neurological and attachment systems, emerge early in the child’s life and can persist into adulthood. Families with complex needs, such as parental substance misuse and psychiatric disorders, are the primary client group of child protection systems across the world, so it is important that targeted interventions are developed to prevent child maltreatment and its associated lifelong harms. 

The PuP extends its focus beyond parenting skills to address the factors underlying poor parenting, such as emotional dysregulation, socioeconomic challenges, and psychopathology. It utilises an individualised modular approach drawing from attachment theory, behavioural parenting skills, and adult psychopathology, and incorporates mindfulness-based strategies. This trial shows that PuP can be effective in reducing self-reported child abuse potential, when delivered by frontline practitioners in a community setting to a heterogeneous sample of parents. 

One potential limitation of the study is that the majority of parents included (96%) were mothers. As the study focused on treatment for primary caregivers engaging in substance misuse treatment, perhaps this highlights that there is an absence of fathers engaging with substance misuse services who have a primary caregiver role. Or perhaps more can be done to identify and engage fathers with SUDs in parenting programmes. This limitation also raises important questions, such as whether or not this programme is effective for fathers, and if there are other settings where PuP, or similar programmes, can be implemented for men. 

Parents with SUDs come into contact with a wide variety of services – criminal justice, primary and secondary health, social care – so it is vital that policy response to this issue is not fragmented and uncoordinated, and that that parenting programmes are available to this high-risk group in a variety of settings. The provision of such programmes should be considered when designing substance misuse services. Likewise, antenatal care providers should receive training to deliver substance misuse interventions and work collaboratively with substance misuse services to engage patients when parental substance misuse is identified.  

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Papers included in the full clinical update:

• Child maltreatment and illicit substance abuse: a systematic review and metaanalysis of longitudinal studies.
  
  
• Substance-use disorders in later life.
  
  
• Which individual, social and environmental influences shape key phases in the amphetamine type stimulant use trajectory? A systematic narrative review and thematic synthesis of the qualitative literature.
  
  
• Drawing attention to a neglected injecting-related harm: a systematic review of AA amyloidosis among people who inject drugs.
  
  
• Implementing peer recovery services for overdose prevention in Rhode Island: an examination of two outreach-based approaches.