April doesn't remember everything that happened on Memorial Day 2015, but she does remember this: A walk with her baby. A couple of beers. A pit stop at the liquor store. And then, the ambulance. The hospital. The child welfare worker at her door the next morning, with a warning: If April wanted to keep her baby, the drinking had to stop.
April desperately wanted to keep her little boy. She'd stayed sober throughout her pregnancy, and when Tyler was born, early and small but healthy and drug-free, April had embraced life as a sober, stay-at-home mom. But as the months wore on, tedium and loneliness rose up. Friends weren't around, and anyway, many of them were from before-before detox, before she'd given up drinking and drugs. Shortly before Tyler's first birthday, April started drinking again. She couldn't hide it and, as much as she wanted to, she couldn't stop it, either. Just a week after Memorial Day, she drank again, and ended up in the hospital, again.
"The next morning they knocked on the door and took the baby. And from that moment on, it became impossible to stay sober."
Babies can't wait
In the 1980s, recognition solidified in the child development field that babies and toddlers are not infinitely resilient. Early experiences change the course of brain development and put children at risk for problems in school and in life later on. Stress and trauma in the early years have been linked to depression, heart disease, and cancer, as well as alcohol and drug use-a vicious generational cycle set in motion even before a baby's first words.
But traditional substance use treatments follow a "fix yourself first" model-get sober, manage your mental health, and then, and only then, are you ready to be Mom or Dad again-and this by-stages model too often fails children at a time when they are developmentally vulnerable, says Ruth Paris, a Boston University School of Social Work associate professor and chair of clinical practice.
"Many children were being removed from parents with substance use disorders, and there was no real effective help for these families," says Paris. "You can't really say to a baby, 'Wait a year until your parent is sober and stable,'" she says.
Paris teamed up with two nonprofits-the Institute for Health and Recovery (IHR) and Jewish Family and Children's Service (JFCS)-to develop and evaluate a program that would help moms and dads bond with their babies at the same time they were getting treatment for substance use and mental health disorders. They named it Project BRIGHT, or Building Resilience through Intervention: Growing Healthier Together, an intervention aimed at improving the parent-child relationship. Paris provided the research know-how, JFCS (which works with families of all faiths) brought its expertise in infant and early-childhood interventions, and IHR added its in-the-field experience in substance use treatment.
BRIGHT reckons with a reality that any new parent who has ever stumbled out of bed at three am to settle a screaming infant knows deep in their tired, rattled bones: taking care of a baby is hard work. Gratitude comes in a quiet, unspoken way: the warmth of the baby cuddling in, the weight of a small sleepy head on your shoulder.
In the best cases, that is thanks enough. But substance use disorders set off brain changes that actually make it harder to experience the joys of new parenthood. After feeling the powerful rush of brain chemicals that comes with a substance like heroin, says Paris, "the small little pleasure of holding a baby against your skin-it may not really register," or it may simply not be enough.
Plus, babies born to moms who used opioids during pregnancy can actually be fussier than average babies. They may cry more often and be more difficult to settle, and they are more likely to have feeding and sleeping problems.
"You couple a parent who is somewhat more compromised in their abilities- although not for lack of wanting to do a better job-and a baby who is coming into the world just a little jittery, and really you have a pretty significant hill to climb," says Paris. The difficult feelings that result-the frustration of failing to calm the screaming baby, the fear of failing as a parent-can be triggers for using again, locking parents with substance use disorders into a downward spiral.
What we're trying to do in this type of intervention is minimize relapse and maximize the parent-child relationship. When mothers or fathers feel better about their parenting, that in turn reinforces recovery.
Project BRIGHT seeks to reverse that spiral by helping mothers and fathers access the small pleasures of parenthood and build stronger relationships with their young children. The idea is that parenting successes inspire sobriety, and vice versa. "What we're trying to do in this type of intervention is minimize relapse and maximize the parent-child relationship," says Paris. "When mothers or fathers feel better about their parenting, that in turn reinforces recovery."
Layering on top of existing treatments, BRIGHT uses the principles of an approach called child-parent psychotherapy, which was developed in the early 2000s as a therapy for parents and children who have experienced abuse or domestic violence. "If there is substance use, there is most likely present or past trauma," says Karen Gould, director of early childhood trauma services at the Institute for Health and Recovery, adding that a parent's substance use is itself traumatic for a child.
BRIGHT, which first launched in 2009, placed visiting counselors at eight residential family treatment centers in Massachusetts. These centers accepted mothers with young children who have nowhere else to live. (One also accepts fathers.) BRIGHT clinicians found that their clients cherished the opportunity to focus on their relationships with their babies. After three years, the team received a four-year grant to continue BRIGHT by placing clinical social workers in three methadone treatment programs. Today, the team is funded by a five-year grant that has placed clinical social workers in Fall River, where they work with patients in methadone, residential and outpatient substance use disorder treatment programs.
Treatment sessions follow guidelines but not a script, says Paris. That gives a clinician the flexibility to follow her client's lead and help her navigate whatever struggles they are working through on that day. The goal is to help the client develop "reflective" skills that connect their thoughts and feelings with specific behaviors. "It's helping them to learn to think and feel and develop those muscles," and then use those skills to better understand themselves and their baby, says Paris. "Attunement is the big piece here," she says. "If you can't figure out your own feelings, it's very difficult to do it with anyone else."
An impossible distance
For April, things got worse before they got better. April's sister had taken custody of Tyler over the spring and summer but, hoping to shock April out of her downward spiral, she decided to place Tyler with a foster family. Tyler's father blamed April; then he relapsed, too. April knew Tyler was safe and well cared for, but that wasn't enough. "I wanted nothing more than for him to be with me."
"I thought, okay, I have to go to detox and then somehow not drink, on my own, and then I got to get a job, get a car, get an apartment, so that I can get my son back," April remembers. "It seemed nearly impossible to accomplish, and it seemed so far away: such a distance between me and my child."
Finally, that winter, a women's advocate helped steer April to a residential treatment program for women with young children. April moved in and had her first visit with Tyler in a matter of days. It was the first time she had seen her son in months.
The treatment program is also where April began seeing a BRIGHT clinician, Cherie. Cherie started meeting with April every week, and with Tyler too when he visited. Tyler's visits became longer and more frequent, and he was even allowed to sleep over some nights. Finally, the day after Tyler's first "double overnight" stay, a judge ordered that Tyler could stay with April at the treatment center indefinitely.
From then on, April and Tyler shared a room. Tyler went to daycare, and sometimes mother and son got a pass to go out together on weekends. Today, April is out of residential treatment, but even after moving on, she continued to talk with Cherie about parenting and recovery, as well as the ordinary minutiae of being a toddler mom: When do I switch to a big-kid bed? What picture books should we be reading? How in the world do I get him to brush his teeth?
"Once you start the process of recovery and getting sober, you can't be around the same people you used to be. You have to change your people, places, and things. You end up getting sober and being in recovery and not having many friends or many supports," April says. "That's one of the reasons I love being able to have Cherie in our lives."
A BRIGHT future
Over the last ten years, BRIGHT has served some 200 parents and young children, and has expanded to serve mothers and fathers in outpatient methadone clinics as well as those in residential treatment. And as BRIGHT has grown, so has the need. When BRIGHT launched, the country was still in the statistical foothills of today's opioid epidemic. Overdose deaths have nearly doubled since 2008, and the number of new mothers with opioid use disorder more than quadrupled between 1999-2014, according to CDC researchers reviewing hospital admission data.
This year, to test BRIGHT's impact with a rigorous research design, a new project called Growing Together is bringing BRIGHT into a prenatal clinic at Boston Medical Center that serves women in addiction recovery. Ruth Rose-Jacobs, a BU School of Medicine associate professor of pediatrics, has joined the team. Growing Together is a clinical trial; some women will see a BRIGHT clinician starting in the third trimester and continuing until their baby's six-month birthday, while others will receive informational parenting handouts.
Prenatal attachment predicts postnatal attachment, and attachment is correlated with so many good things. Starting an intervention while a woman is pregnant gives her the chance to connect with her unborn child and to anticipate the joys and challenges of parenting while in recovery.
At the six-month mark, participants in both groups will be videotaped, capturing interactions between parents and their children. The clinical research team will be watching the videos to assess how well each parent can pick up on the nonverbal cues of their baby. "Mothers and fathers with opioid use disorder and other substance use disorders often misread the cues of their child," Paris says. That means a parent might not notice that a child turning his face away or putting his hands up is signaling the need for some space. "What does a parent think is going on in their child's mind? How are a parent's emotions responding to nonverbal cues?" she says. The better a parent is able to pick up on a child's cues, the stronger the attachment between parent and child.
Growing Together builds on a key insight that Paris and her collaborators have learned over the years: The best time to start bonding is before a baby is even born. "Prenatal attachment predicts postnatal attachment, and attachment is correlated with so many good things," says Paris. "Starting an intervention while a woman is pregnant gives her the chance to connect with her unborn child and to anticipate the joys and challenges of parenting while in recovery."
Not everyone's story goes like April's, and Paris cautions that relapse is a part of recovery: treatment can minimize it, but rarely eliminate it. But April is aiming to be the exception. "I know that if I ever pick up a drink or drug again, I'm going to lose him, and I can't even deal with that thought," she says. "That's just not an option for me."
Project Bright received funding from SAMHSA (Substance Abuse and Mental Health Services Administration, HHS) through the National Child Traumatic Stress Network. The Growing Together study is funded by HRSA (Health Resources and Services Administration, HHS).
