A Type I Hybrid Effectiveness-Implementation Trial of MIO

Pregnancy and parenting can be life-changing motivators for women with substance use disorders (SUDs) to seek treatment. However, the rate of relapse and overdose for women with SUDs increases sharply after the birth of a child, such that mental health and drug-related deaths are a leading preventable cause of postpartum mortality. Heightened parental stress and lack of adequate parenting supports increase the risk of drug overdose. Mothers with SUDs are also more likely to exhibit maladaptive parenting behaviors associated with long-term developmental, behavioral, and emotional problems in their offspring. Despite the well-established interaction between parenting and SUDs during a critical period, SUD treatment does not systematically include targeted parenting support for mothers in recovery and their young children.

Mothering from the Inside Out (MIO) is an evidence-based, individual parenting intervention designed as an adjunct to outpatient SUD treatment that targets parental reflective functioning, i.e., the capacity to understand behavior, for oneself and one's child, in terms of underlying mental states. MIO has proven bigenerational efficacy in two randomized trials when delivered by researchers under tightly controlled research conditions. Mothers assigned to MIO demonstrated significantly improved parenting capacities and reduced substance use compared with those assigned to parental education.

Although MIO was efficacious when delivered by expert clinicians in highly organized research settings, there are challenges to exporting any evidence-based practice to dynamic real-world environments creating a science-to-service gap. As a first step in addressing these challenges, we successfully trained SUD and mental health counselors to deliver MIO with fidelity in community clinics. Yet, in the only community-based efficacy trial where MIO was delivered by SUD treatment counselors, MIO offered some advantages over parental education with respect to reduction in substance use and depressive symptoms, but MIO did not yield the same magnitude of improvement in parenting as it did in the first two randomized controlled trials.

Community-academic partnerships and governmental funding support in Massachusetts have since allowed our multi-disciplinary team to identify barriers to implementation and develop a practice-informed implementation strategy to mitigate these barriers. We are now poised to simultaneously test the clinical effectiveness of MIO and the utility of our implementation strategy in community-based clinical settings. With guidance from our two community partners, we are proposing a Hybrid Type II research project to test the effectiveness and implementation of MIO as an adjunct to treatment as usual (TAU). SUD counselors (n=16) and mothers enrolled in outpatient SUD treatment (n=200) caring for children ≤5 years of age will be recruited from four SUD treatment clinics operated by two community agencies in Massachusetts. These sites were selected by our community partners based on their generalizability and engagement with parents with SUDs. Mothers will be randomized in a 2:1 fashion to the receipt of either MIO+TAU or TAU to allow for dual examination of the implementation process as well as the MIO mechanism of change. Guided by established frameworks and our implementation conceptual model, we will use a mixed-methods approach to evaluate the relationship between key contextual determinants of MIO implementation. Our specific aims include the following:

Aim 1. Compare the effectiveness of MIO+TAU versus TAU alone. Hypotheses: Compared with mothers receiving TAU, mothers randomized to MIO+TAU will demonstrate a greater increase in parental reflective functioning and greater decrease in parenting stress (primary outcomes) at the end of treatment. They will also demonstrate greater improvement in quality of mother-child interactions and greater decreases in drug use and psychiatric distress (secondary outcomes) at 3-month follow-up.

Aim 2. Assess differences in agency- and clinic-level implementation processes with respect to a) completion of implementation activities, b) tailoring strategies, and c) implementation outcomes.

Hypothesis: Facilitated completion of pre-implementation activities at the agency- and clinic-level will predict greater reach, adoption, feasibility, and fidelity of MIO across four clinical units.

Aim 3. Identify key contextual determinants associated with successful MIO implementation and effectiveness, supported by integration of qualitative and quantitative data to guide large-scale dissemination.

Hypothesis 3a: Primary implementation outcomes (MIO fidelity and feasibility) will be determined by organizational climate, characteristics of individual counselors, and execution of the implementation process integrity.

Hypothesis 3b: The association between primary implementation outcomes (MIO fidelity and feasibility) and secondary effectiveness outcomes (quality of mother-child interactions, maternal drug use, and psychiatric distress) will be mediated by parental reflective functioning and parenting stress (primary effectiveness outcomes).

Moving evidence-based practices into routine care settings is a public health and NIDA priority. When completed, this project will allow us to address the critical gap between research and practice by providing data to support large-scale implementation of MIO in community settings.