Evidence Base

PCAP is based on the tenet that effective intervention programs for high‐risk mothers take into account the complex nature of the women’s problems, and provide services that are multidisciplinary, comprehensive, coordinated, and include the children. PCAP evaluation therefore examines multidimensional outcomes, improved overall social functioning, and reduction of risk to the mother and target child. PCAP has been evaluated using blended evaluation designs; outcomes have been published in five peer‐reviewed papers.

Study 1. Original Demonstration Cohort (1991 – 1995)

Ernst, C.C., Grant, T.M., Streissguth, A.P., & Sampson, P.D. (1999). Intervention with high‐risk alcohol and drug‐abusing mothers: II. 3‐year findings from the Seattle model of paraprofessional advocacy. Journal of Community Psychology, 27(1): 19–38.

Hospitalized postpartum women were screened for eligibility and randomly assigned to home visitation intervention (n=30) or the community standard of care control group (n=31).

Referrals meeting the same eligibility criteria were also accepted from community service providers and assigned to the intervention group (n = 35).  Data from community-referred clients was analyzed separately. Participants were interviewed pre and post-intervention using a structured interview adapted from instruments used by the authors in prior studies (Grant et al., 1994; Streissguth et al., 1981, 1993).

To measure overall effectiveness of the program, two composite variables were created: a baseline (intake) score, and an endpoint score to assess status at 36 months. Each of these composite variables incorporates five domains theorized a priori to be most affected by the intervention:

1. Utilization of alcohol/drug treatment

2. Abstinence from alcohol and drugs

3. Family planning (use of birth control, subsequent pregnancies)

4. Health and well-being of target child (health care, custody)

5. Appropriate connection with community services at 36 months

Each domain is comprised of items on which a subject was scored on a 5-point scale. Item scores were summed to compute domain scores and domain scores summed to compute the total summary score. Cronbach’s alpha (computed from the five component domain scores) was .91 for the baseline score and .82 for the endpoint score.

Data from the 36-month post-intervention interview indicated that hospital-recruited clients (n=28) scored significantly higher than hospital-recruited controls (n=25) on the endpoint score (endpoint mean: clients = 17.1 vs. control = 10.1, t = -2.11, p <.04).  Adjusting for the baseline scores (baseline mean: clients = -21.8; controls = -18.5) we found a stronger intervention effect (p <.02).  Three-group analysis of covariance (hospital-recruited clients, community referred clients, and hospital-recruited controls) indicated positive intervention effects among both client groups compared to controls (p<.05).

Study 2.  Post-Program Follow-Up Cohort (1997 – 1998)

Grant, T., Ernst, C.C., Pagalilauan G. & Streissguth, A.P. (2003). Post-program follow-up effects of paraprofessional intervention with high-risk women who abused alcohol and drugs during pregnancy. Journal of Community Psychology, 31(3): 211–222.

Study 2 was a post-program follow-up of Study 1 intervention group subjects who were located for interview 1.6 to 3.6 years after exit from the 3-year PCAP intervention.  A total of 48 intervention group subjects were located.  Among the 45 mothers on whom we had interview data at the three measurement points (PCAP enrollment, PCAP exit, and follow-up), we found statistically significant improvements as follows.

Between PCAP exit and post-program follow-up:

Study 3. Seattle and Tacoma Replication Cohorts (1996 – 2003)

Grant, T., Ernst, C., Streissguth, A. & Stark, K (2005). Preventing alcohol and drug exposed births in Washington State: Intervention findings from three Parent-Child Assistance Program sites. American Journal of Drug and Alcohol Abuse, 31(3): 471-490.

In 1996 PCAP obtained state funding to replicate the intervention in Seattle and Tacoma, the two largest cities in Washington State. Funds were not made available to enroll a control group.  Study 3 is a cohort study, pretest–posttest comparison examining 36-month outcomes from: the original demonstration (OD) (described in Study 1 above), the Seattle replication site (SR) (1996–2003), and the Tacoma replication site (TR) (1996–2003).  Subjects enrolled after 1996 (n=84) were interviewed using the 5th edition Addiction Severity Index (ASI), a widely used standardized instrument demonstrating good reliability and validity.

Comparing data across the OD (n=60), SR (n=76), and TR (n=80), slopes for the regression of endpoint score on baseline score were similar across the groups. Each of the replication samples performed significantly better than the OD (p <.02), adjusting for baseline score.

Compared to the OD, at exit from the intervention a higher proportion of SR and TR subjects:

Compared to the OD, at exit from the intervention a lower proportion of SR and TR subjects:

Study 4.  Maternal Substance Abuse and Disrupted Parenting: Distinguishing Mothers Who Keep Their Children From Those Who Do Not

Grant, T., Huggins, J., Graham, C., Ernst, C., Whitney, N., and Wilson, D. (2011). Maternal substance abuse and disrupted parenting: Distinguishing mothers who keep their children from those who do not. Children and Youth Services Review, 33(11): 2176-2185.

Women with substance abuse disorders typically have psychosocial characteristics that put them at risk for disrupted parenting. Prior research indicates that comprehensive, accessible services tailored to the mothers’ needs can contribute to family stability. This study further explores the complicated interplay of how maternal risk and protective characteristics and service elements are associated with reunification. The study contributes to existing literature by following mothers for three years; examining service needs as identified by the mother herself; using a summary proportion score to reflect the totality of services received to matched service needs identified; and using logistic regression to examine interactions of services received with critical maternal characteristics. The sample is comprised of 458 substance-abusing mothers enrolled during pregnancy or postpartum in the Washington State Parent–Child Assistance Program (PCAP), an evidence based case management intervention. Participants’ custody status was well distributed among four categories based on continuity of parenting. Findings indicate that at program exit 60% of the mothers were caring for their index child. These mothers had more treatment and mental health service needs met, had more time abstinent from alcohol and drugs, secure housing, higher income, and support for staying clean and sober. Among women with multiple psychiatric diagnoses, the odds of regaining custody were increased when they completed substance abuse treatment and also had a supportive partner. Mothers who lost and did not regain custody had more serious psychiatric problems and had fewer service needs met. We discuss implications of our findings for child welfare policy and practices.

Study 5.  Improving Pregnancy Outcomes Among High-Risk Mothers Who Abuse Alcohol and Drugs: Factors Associated With Subsequent Exposed Births

Grant, T.M., Graham, J.C., Ernst, C.C., Peavy, K.M., & Brown, N.N. (2014). Improving pregnancy outcomes among high-risk mothers who abuse alcohol and drugs: Factors associated with subsequent exposed births. Children and Youth Services Review, 46: 11-18.

Parental alcohol and drug abuse is a factor in approximately 15% of the cases investigated by the child welfare system and in approximately one quarter of cases with substantiated maltreatment. While substance abuse treatment is generally an essential component of child welfare family plans, a relatively low proportion of substance abusing mothers involved in the child welfare system complete treatment, which typically results in placement of their children in substitute care and the beginning of a new generation of adaptive problems. This longitudinal study explores whether loss of an index child due to substance abuse is associated with risk of a subsequent alcohol/drug-exposed birth in a sample of 795 substance-abusing mothers enrolled in the Washington State Parent–Child Assistance Program (PCAP). Results indicate that at program exit, over one-fifth of these women had a subsequent birth (SB) after the birth of their index child. Among these women, over half (i.e., 56.3% or 12.3% of the entire sample) used alcohol and/or drugs during the subsequent pregnancy. Consistent with our main hypothesis, the adjusted odds of having a SB were increased nearly two-fold for women who had the index child removed from their care. Furthermore, among mothers with subsequent births, the adjusted odds of having an exposed SB were increased three-fold if the index child had been removed from the mother’s care. We discuss implications of our findings for child welfare policy and practices.

Study 6.  Use of Marijuana and Other Substances Among Pregnant and Parenting Women With Substance Use Disorders: Changes in Washington State After Marijuana Legalization

Grant, T.M., Graham, J.C., Carlini, B.H., Ernst, C.C., & Brown, N.N. (2018).  Use of marijuana and other substances among pregnant and parenting women with substance use disorders: Changes in Washington State after marijuana legalization. Journal of Studies on Alcohol and Drugs, 79(1), 88-95.

In 2012, possession of marijuana for non- medical use was legalized in Washington State. This study examined how legalization affected alcohol and drug use in a sample of pregnant and parenting women with substance use disorders and enrolled in the Parent–Child Assistance Program (PCAP). Study participants from nine counties in Washington State (N = 1,359) were questioned about their substance use after completing the 3-year PCAP intervention. The sample was divided into two cohorts based on whether participants had completed PCAP before or after legalization. Study results indicated that overall, most study participants (62%) reported complete abstinence from alcohol and nonprescription drugs at PCAP exit. Among those who were still using substances, women who completed the intervention after marijuana legalization (Cohort 2) were significantly more likely to report marijuana use at program exit compared with women who completed the intervention before marijuana legalization (Cohort 1). Among study participants who did not achieve abstinence during the intervention, across both cohorts (pre- and post-legalization), we found a positive association of exit marijuana use with alcohol, illegal methadone, other opioids, amphetamines, and cocaine use; exit marijuana use was associated primarily with alcohol use. We conclude that marijuana use at PCAP exit increased significantly after marijuana legalization in the state. Women who were not abstinent from marijuana at program exit were likely to report use of other substances as well. Our study design demonstrates an association but does not allow us to conclude that marijuana use leads to other substance use among this sample of women with a history of polysubstance use.

Study 7.  Prevention of Methamphetamine Abuse: A Pilot Intervention with Drug-Endangered Children and Their Mothers

Accepted to Infant Mental Health Journal:  Predictors and moderators of improved social-emotional functioning in mothers with substance use disorders and their young children enrolled in a relationship-based case management program  Hildebrandt U, Graham, JC, Grant, TM