Parental Mental Illness DTW

Key Points

• General Information: Mood swings are common in the days/months after childbirth; Depression, however, is more severe and persistent and includes:
• loss of interest or enjoyment in things that have usually given pleasure, emotional emptiness, and a feeling of "flatness"
• lasting 2 weeks or longer (see definitions).
• often affects self-esteem, appetite, sleep, energy, and concentration.
• Postpartum Depression Facts: (PT)
• Leading cause of disease burden in women 15-44. Will replace cancer as 2nd leading cause of morbidity in the next decade.
• Affects 10-15% of women in the months after birth, about half will continue up to one year.
• Average duration of an episode is 7 months without treatment.
• Less than 50% identified and, even if identified, less than 50% are treated.
• Risk Factors: Low income, low education, poor health status, many children, stressful life events, prior personal or family history of depression.
• Etiology: poorly understood; multifactorial.
• DSM-IV Criteria for Major Depression (American Psychiatric Association 1994) :
• At least one of the following abnormal moods that interfered with a person's l ife most of the day nearly every day for at least 2 weeks: 1) depressed mood; and/or 2) loss of all interest and pleasure.
• At least 5 of the following have also been present in the same two-week period:
• Appetite or weight disturbance (weight loss when not dieting or decrease in appetite) (weight gain or increase in appetite);
• Sleep disturbance, either abnormal insomnia or abnormal hypersomnia;
• Activity disturbance, agitation or abnormal slowing;
• Fatigue or loss of energy;
• Abnormal self-reproach or inappropriate guilt;
• Poor concentration or indecisiveness;
• Abnormal morbid thoughts of death or suicide.
• Symptoms not due to: mood-incongruent psychosis, physical illness, alcohol, medication, street drugs, normal bereavement or bipolar disease.
• Related emotional conditions:
• Postpartum blues: a transient alteration of mood that occurs in 50-60% of postpartum women. It typically lasts only 24-48 hours.
• Postpartum depression: occurs in approximately 10-20% of women and lasts 6-8 weeks. Symptoms are comparable to depression at other times of life. Risk factors for postpartum depression include depression prior to or during pregnancy, poor social support, high stress level, and poor relationship with partner (Horowitz, J.A. 2005) .
• Postpartum psychosis: occurs in only 1 or 2 out of 11,000 mothers. Symptoms are similar to non-postpartum depressive psychosis. This serious condition frequently requires medication, hospitalization, and significant family support.
• Impact on parenting:
• Altered parenting including: more irritable and negative, more easily annoyed, less consistent in discipline, less able to pay attention and respond to children's needs, less able to provide support/encouragement and a well-structured routine, spend less time playing with their children.
• Decreased use of prevention strategies (use of car seats, use of electrical outlet covers, availability of syrup of ipecac in the home; (McLennan, J.D. 2000) ).
• Other health risks increased:
• household food insecurity status, lower maternal reported child health status, and more hospitalizations during the child's lifetime (Casey, P. ) ;
• health/mental health expenditure for children (Olfson, M. 2000) .
• Impact on children and families:
• Increased risk of childhood mental health problems: major depression, conduct disorder, substance use, and anxiety disorder (Casey, P. ) ; (Wickramaratne & Weissman, 1998).
• Poorer family functioning, decreased marital satisfaction, and children?s behavior problems (Seifer, R. 2001) .
• Poorer cognitive outcome in the toddler period (Murray, L. 1996) due to mother-infant relationship disturbances.
• Altered infant attachment (e.g. Martins & Gaffan, 2000; Seifer et al., 1996), although severity of depression and other comorbid illnesses may be critical factors to impact on the child (Carter, A.S. 2001) . Cumulative risk models, in which the total number of stressors (poverty, etc.) are considered, may be most effective in predicting the impact of maternal depression on child/family functioning (e.g. Dickstein et al., 1998).
• Long-term depression has worse effects on child development than short-term (Petterson, S.M. 2001) .
• Depression during pregnancy effects:
• Possibly more difficult temperament (by parent report) among infants of mothers with depression and anxiety during pregnancy (Austin, M.P. 2005Austin, M.P. 2005) .
• Possibly worse neonatal outcomes such as prematurity and low birth weight with prenatal depression/anxiety (Andersson, L. 2004) ; (Misri, S. 2004Misri, S. 2004) .
• Depression in fathers:
• In families with a depressed mother, depression in the father may have an additive effect. Research specifically assessing the impact of paternal depression on children and families is limited. (Burke, L. 2003)
• Suggestive links between depression in one partner and psychiatric symptoms in the spouse (Miller, I.W. 2000) .

Latest research on Parent Depression

Management

• Recognition: Often difficult to distinguish between the expected mood swings and depression.
• Most new parents experience disruptions in sleep patterns, energy level, and ability to focus, all of which are associated with depression.
• New parents are often eager to project an air of competence and may be reluctant to discuss emotional distress.
• Role of the Pediatrician: Early detection through a reliable and valid screening method:
• US Preventative Task Force Questions
• "Over the past two weeks, have you felt down, depressed, or hopeless?"
• "Over the past two weeks, have you felt little interest or pleasure in doing things?"
• CHADIS includes the 2 question Primary Care Evaluation of Mental Disorders?.
• Other instruments available for further screening and assessment include:
• Edinburgh Postnatal Depression Scale (Cox, J.L. 1996) (Link to EPDS)). 10 items, Clinical Cutoff is 10-12.
• Beck Depression Inventory (Beck, A.T. 1961)
• Center for Epidemiologic Studies Depression Scale (Radloff, L.S. 1977)
• Assessment in the office:
• Note questionnaire responses
• Observe parent (expressionless/flat affect or restless, speaks in monotone; reports difficulty or confusion in parenting; little interest in the child; overly anxious or protective).
• Ask something like:
• "How have you been feeling? Your baby needs you to be happy and healthy." Follow-up questions (2 or more "yes" responses=probable depression):
• Have you been feeling sad, blue, or depressed?
• Are you having trouble sleeping?
• Have your eating habits changed?
• Has any blood relative suffered from depression?
• Have you ever suffered from depression before? If so, how was your depression treated?"
• Intervention Strategies: (from Bright Futures Mental Health, pp. 303-307)
• Early recognition
• Support/telephone follow-up
• Inquire about resources/supports in parents? environments
• Offer to initiate a referral if depressed and not in treatment
• Inquire about suicidal ideation or actions if depressed - immediate referral if any ideation. A note or phone call to the treating doctor is useful to alert him or her regarding impact on the child; some pediatricians begin treating the parent themselves.
• Pharmacotherapy: SSRIs were more effective than placebo, but not unlike tricyclics, with the exception of a lower rate of dropout due to side effects. (Mulrow et al., 2000)
• Treatment of postpartum depression: (from a review by Gjerdingen, 2003):
• Antidepressant treatment: Pharmacotherapy appears effective (Gjerdingen cites studies of sertraline, fluvoxamine, and venlafaxine) although research is relatively limited.
• Breastfeeding and antidepressants:
• Antidepressant serum levels among breastfed babies of mothers undergoing pharmacotherapy were "either not detectable or very low" (Gjerdingen, p. 374).
• In a few cases, adverse effects were noted (e.g. crankiness, vomiting, diarrhea, and adverse effects on sleep). Weight differences may be noted among babies exposed to fluoxetine versus non-exposed infants.
• FDA has not approved antidepressants for nursing mothers, but since there are potential adverse effects of untreated maternal depression on both mothers and infants these need to be weighed (Gjerdingen). "If the potential benefits are thought to be greater, paroxetine, sertraline, and nortriptyline could be considered as initial drug therapy options...
• Fluoxetine should be avoided, and citalopram, doxepin, and nefazodone used only cautiously, because adverse effects have been associated with their use" (p. 377).
• Hormonal treatment:
• Limited evidence supports estrogen therapy for women with postpartum depression and postpartum psychosis.
• No effect for progesterone.
• Psychotherapy:
• Individual therapy- Four randomized controlled studies suggest effectiveness.
• Group therapy- research results more mixed.
• Home Visiting: Two randomized controlled studies suggest effectiveness.
• Other treatment options: Other therapies showing some positive results include: light therapy, massage, and ECT.

References

1. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
2. Andersson, L., Sundstrom-Poromaa, I., Wulff, M., Astrom, M., Bixo, M. (2004). Neonatal outcome following maternal antenatal depression and anxiety: A population-based study. .
3. Austin, M.P., Hadzi-Pavlovic, D., Leader, L., Saint, K., Parker, G. (2005). Maternal trait anxiety, depression and life event stress in pregnancy: relationships with infant temperament. .
4. Beck, A.T. (1961). Beck Depression Inventory.
5. Burke, L. (2003). The impact of maternal depression on familial relationships. .
6. Carter, A.S., Garrity-Rokous, F.E., Chazan-Cohen, R., Little, C., Briggs-Gowan, M.J. (2001). Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. .
7. Casey, P., Goolsby, S., Berkowitz, C., Frank, D., Cook, J., Cutts, D., et al. (). Maternal depression, changing public assistance, food security, and child health status. .
8. Chaudron, L.H., Szilagyi, P.G., Kitzman, H.J., Wadkins, H.I.M., Conwell, Y. (2004). Detection of postpartum depressive symptoms by screening at well-child visits. .
9. Cox, J.L., Chapman, G., Murray, D., Jones, P. (1996). Validation of the Edinburgh Postnatal Depression Scale (EPDS) in non-postnatal women. .
10. Dickstein, S., Seifer, R., Hayden, L.C., Schiller, M., Sameroff, A.J., Keitner, G., et al. (1998). Levels of family assessment II: Impact of maternal psychopathology on family functioning. .
11. Gjerdingen, D. (2003). The effectiveness of various postpartum depression treatments and the impact of antidepressant drugs on nursing infants. .
12. Horowitz, J.A., Goodman, J.H. (2005). Identifying and treating postpartum depression. New York: Guilford Press.
13. Lieb, R., Isensee, B., Hofler, M., Pfister, H., Wittchen, H. (2002). Parental major depression and the risk of depression and other mental disorders in children. .
14. Martins, C., Gaffan, E.A. (2000). Effects of early maternal depression on patterns of infant-mother attachment: A meta-analytic investigation. .
15. McLennan, J.D., Kotelchuck, M. (2000). Parental prevention practices for young children in the context of maternal depression. .
16. Miller, I.W., McDermut, W., Gordon, K.C., Keitner, G.I., Ryan, C.E., Norman, W. (2000). Personality and family functioning in families of depressed patients. .
17. Misri, S., Oberlander, T.F., Fairbrother, N., Carter, D., Ryan, D., Kuan, A.J., et al. (2004). Relation between prenatal maternal mood and anxiety and neonatal health. .
18. Murray, L., Fiori-Cowley, A., Hooper, R., Cooper, R. (1996). The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. .
19. Olfson, M., Marcus, S.C., Druss, B., Pincus, H.A., Weissman, M.M. (2003). Parental depression, child mental health problems, and health care utilization. .
20. Petterson, S.M., Albers, A.B. (2001). Effects of poverty and maternal depression on early child development. .
21. Radloff, L.S. (1977). The CES-D scale: a self-report depression scale for research in the general population. .
22. Seifer, R., Sameroff, A.J., Dickstein, S., Keitner, G., Miller, I., Rasmussen, S., et al. (1996). Parental psychopathology, multiple contextual risks, and one-year outcomes in children. .
23. Seifer, R., Dickstein, S., Sameroff, A.J., Magee, K.D., Hayden, L.C. (2001). Infant mental health and variability of parental depression symptoms. .
24. Stowe, Z.N., Hostetter, A.L., Newport, D.J. (2005). The onset of postpartum depression: Implications for clinical screening in obstetrical and primary care. .
25. U.S. Preventive Services Task Force (2002). Screening for Depression: Recommendations and Rationale. .
26. Wyckramaratne, P.J., Weissman, M.M. (1998). Onset of psychopathology in offspring by development phase and parental depression. .

Key Points

• Prevalence:
• 23.9% of people will have an anxiety disorder in their lifetime; 14.6% have one currently ( [broken reference] ) .
• Mild impairment if anxiety disorders alone (Nisenson); other studies report more significant patient distress in primary care samples (e.g. Olfson et al., 2000).
• Comorbidity:
• High (e.g. 69.8% of those with anxiety have an additional disorder per Nisenson et al., 1998)
• Those with more comorbidity have greater impairment (e.g. Olfson et al., 2000).
• Comorbidity with depression is especially high, may help detect depression (Nisenson, L.G. 1998) .
• Effects of anxiety during pregnancy on child outcomes:
• Temperament: Maternal depression and anxiety during pregnancy associated with parent report of difficult temperament among infants (Austin, M.P. 2005Austin, M.P. 2005) .
• Neonatal: Possible increase in prematurity and low birth weight with prenatal d epression/anxiety (Andersson, L. 2004) ; (Misri, S. 2004Misri, S. 2004) ).
• Preschool/school age: Possible link between maternal anxiety during pregnancy and increased rates of ADHD, externalizing/behavior, and anxiety symptoms (O'Connor, Heron, Golding, Beveridge, & Glover, 2002); (Van den Bergh, B.R. 2004) .
• Effects of parental anxiety on parenting:
• Altered parent-child interaction, e.g. increased control and criticism, decreased warmth (Whaley, S.E. 1999) , increased withdrawal and disengagement (Woodruff-Borden, J. 2002) but questions remain as to whether this is due to parental anxiety, or general parental psychiatric symptomatology.
• Effects on children and families:
• Higher rates of psychopathology in children: Compared to children of non-disordered parents (Beidel, D.C. 1997) ; (Whaley, S.E. 1999) ; Beidel and Turner found this to be true whether anxiety was the only parental disorder, or whether comorbid depression was evident, with lower SES associated with increased risk for children.
• Modeling of fears for the child (e.g. parent acts afraid of dogs; child becomes afraid of dogs)
• Vulnerable child syndrome may be the presentation of parent anxiety disorder
• Munchausen by Proxy (parent creates symptoms or signs of illness in the child and demands medical treatment- a rare manifestation
• Genetic influences: Anxiety is often inherited, complicating the etiological chain and also making management of the child's anxiety more difficult

Latest research on Parent Anxiety

Definitions

Same as for DSM Disorders in children (See Anxiety definitions)

Management

• Consider parental anxiety and ask about it. Example questions include:
• You seem pretty anxious about this. Do you find yourself worried or anxious a lot?
• Are you anxious about things other than your child's health?
• Is anyone else in the family a "worrier"?
• How bad does it get?
• Do your worries keep you from doing things you might do otherwise?
• Refer for cognitive behavioral therapy (CBT), the most effective treatment.
CBT is associated with more sustained recovery than medications. Components of CBT work best as a package and include:
• Reframing the situation in a more positive light (You care so much about keeping her safe)
• Relaxation exercises
• Exposure/desensitization paired with relaxation
• Strategies for the primary care visit
• Specify duration of the visit at the beginning (to allow parent to set priorities and avoid disappointment)
• Set structure and promote coping:
• Encourage parent to make a list of prioritized concerns
• Have parent reflect on past coping in other situations to draw strength
• Have parent pretend to be a real or imagined role model who could handle the situation
• Elicit associations from the past for the current emotion to create distinctions
• Make plans for how parent will handle key situations then have them practice in imagination
• Enlist supports for stressful times (e.g. other parent to assist with bedtime fears)
• Praise parent's increased independence in handling situations
• Invite frequent contact by phone or visit at a time convenient to clinician

References

1. Andersson, L., Sundstrom-Poromaa, I., Wulff, M., Astrom, M., Bixo, M. (2004). Neonatal outcome following maternal antenatal depression and anxiety: A population-based study. .
2. Austin, M.P., Hadzi-Pavlovic, D., Leader, L., Saint, K., Parker, G. (2005). Maternal trait anxiety, depression and life event stress in pregnancy: relationships with infant temperament. .
3. Beidel, D.C., Turner, S.M. (1997). At risk for anxiety: I. Psychopathology in the offspring of anxious parents. .
4. Misri, S., Oberlander, T.F., Fairbrother, N., Carter, D., Ryan, D., Kuan, A.J., et al. (2004). Relation between prenatal maternal mood and anxiety and neonatal health. .
5. Nisenson, L.G., Pepper, C.M., Schwenk, T.L., Coyne, J.C. (1998). The nature and prevalence of anxiety disorders in primary care. .
6. Olfson, M., Shea, S., Feder, A.D., Fuentes, M., Nomura, Y., Gameroff, M., et al. (2000). Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice. .
7. Van den Bergh, B.R., Marcoen, A. (2004). High antenatal maternal anxiety is related to ADHD symptoms, externalizing problems, and anxiety in 8- and 9-year-olds. .
8. Whaley, S.E., Pinto, A., Sigman, M. (1999). Characterizing interactions between anxious mothers and their children. .
9. Woodruff-Borden, J., Morrow, C., Bourland, S., Cambron, S. (2002). The behavior of anxious parents: Examining mechanisms of transmission of anxiety from parent to child. .

Key Points

• Prevalence:
• Alcoholism occurs in one of eight adults in the US; one in six children has an alcoholic parent (Healthy Steps).
• Alcohol is the most likely substance of abuse to cause damage to the child
• Partners likely to be involved also
• Impact on children and families:
• Increased risk of physical and sexual abuse; more psychosomatic illnesses; emotional, anxiety, and conduct disorders; and school problems including hyperactivity in substance abusing families (Werner, Joffe & Graham, 1999 p. 1099).
• Maternal substance abuse associated with increased internalizing and externalizing symptomatology, lower IQ, and poorer academic achievement among boys (Moss, H.B. 1995) .
• Substance use disorders in adolescents increased with parental substance abuse ( [broken reference] ) .
• Special issues for addicted women (Healthy Steps): Women face unique problems related to addiction.
• Physiological response to alcohol and cocaine differs from that of men, causing their health to deteriorate more quickly.
• Stigma and shame: Women are viewed as caretakers, frequently hide their addictions to maintain family stability; often not encouraged to get treatment.
• Mothers risk losing children if they seek treatment. Drug treatment that includes childcare or services for pregnant women is quite rare.
• Substance use during pregnancy:
• Alcohol use during pregnancy can cause fetal alcohol syndrome or more subtle developmental or behavioral disorders. Fetal alcohol syndrome gets worse with each pregnancy as liver loses efficiency to detoxify and use increases.
• Other legal and illegal drugs used during pregnancy can also affect fetal growth/development.
• Cocaine exposure in utero associated with "lower arousal, poorer quality of movement and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes" for infants at one month (Lester et al., 2002, p. 1182).
• Links between in utero cocaine and tobacco exposure and lower birth weight and head circumference (Shankaran, S. 2004) .
• Racial and ethnic considerations: Despite similar or lower rates of alcohol consumption, black and Hispanic individuals appear to be at greater risk for negative consequences of alcohol use, including both physical consequences (e.g. cirrhosis, fetal alcohol syndrome) and social ones (e.g. financial, legal, and interpersonal problems) (Wallace, J.M. 1999) . Wallace attributes this discrepancy to the generally increased levels of risk faced by African American and Latino families (e.g. greater likelihood of lower SES and other stressors).

Management

(adapted from Werner, Joffe & Graham, 1999; other sources as noted)

• General screening issues: For a review, see Werner et al. (1999)
• Family substance use is among the most important issues to assess, given the enormous impact substance use may have on the child's current and future health.
• Drug and alcohol use should be screened as part of history and when concerns are raised regarding "family dysfunction, child behavior or emotional problems, school difficulties, and recurring episodes of apparent accidental trauma, and in the setting of recurrent or multiple vague somatic complaints by the child or adolescent" (p. 1100)
• Also suspect if: unusual times of visits, unusual behavior, unkempt, secretive, marital discord
• Screening Questions include the following:
• Questions from Kemper & Babonis, 1992:
• Have you ever had a drinking problem?
• Have you tried to cut down on alcohol in the past year?
• How many drinks does it take for you to feel high or get a buzz?
• Do you ever have more than 5 drinks at one time?
• CAGE (Ewing, J.E. 1984) ; in adults, >1 positive response is associated with alcohol abuse or dependency, per Bush, Shaw, Cleary, Delbanco, & Aronson, 1987):
• C-Have you ever felt a need to Cut down on your use of alcohol or drugs?
• A-Have you ever gotten Annoyed by someone?s criticism of your alcohol or drug use?
• G-Do you ever feel Guilty or bad about your alcohol or drug use?
• E-Do you ever use alcohol or drugs Early in the morning?
• Screening during the prenatal visit (Werner et al., p. 1103): The prenatal visit is ideally framed in terms of concern for fetal health, nutrition during pregnancy, family history.
• "It may be less threatening to first ask whether there have been alcohol or other substance-abuse problems in the parents? families."
• "Questioning may start addressing the use of over-the-counter medications, then prescription medications, then smoking, then alcohol and, finally, other drugs."
• Try saying: "Many parents seem to be confused about whether it is safe to drink alcohol during pregnancy. What is your understanding?"
• Screening during infancy and early childhood (Werner et al., p. 1103): When interview raises concerns about parent, substance use should be further screened.
• Try saying: "People handle stress in different ways. Some people exercise, some sleep, some people eat more, others smoke cigarettes or use alcohol or other drugs. How are you handling it?"
• This "raises an important issue, gives feedback to the parents, and establishes the willingness of the provider to discuss the issue at a later time if needed."
• Screening among families with school-aged children:
• By 7 or 8, children can answer questions like "Do you think that anyone in your family has a problem with alcohol or other drugs? Do you think that either your mother or father drinks alcohol too much? Have you seen either your mother or father use drugs?" (Werner et al., p. 1105).
• Suggested anticipatory guidance to child:
• What (if any) guidance children have received, either at school or home, and the extent to which children comprehend such guidance.
• Discussion of substance use by peers
• Perceptions of reasons for and consequences of substance use.
• Screening among families with adolescents:
• Routine part of adolescent visit
• Potential questions (Werner et al., p. 1105):
• "Has anyone in your household or your family ever neglected their usual responsibilities when drinking or taking drugs?"
• "Have you ever felt someone in your household or family should cut down on their drinking or drug taking?"
• "Do you ever wish someone in your family didn?t drink so much?... Who is that?"
• Treatment:
• Encourage parents to begin treatment- 70% eventually succeed (see CHADIS resource database)
• Identify "where they are" and what they are willing to do now (Miller, I.W. 2000) .
• Look for and pursue treatment for "comorbid" issues for which they may be more motivated
• Keep in mind that the benefits of quitting motivate more than adverse consequences
• Communication techniques:
• Communication around family substance use can be difficult. Werner and colleagues suggest "genuine concern combined with clear feedback" for example, ?I am concerned that your husband?s alcohol use may be causing a problem for the family... or may be affecting your son?s health" (Werner et al p. 1110).
• Maintaining a dual focus on the needs of both the substance-abusing individual and his or her family is challenging. "Statements such as ?Dealing with substance-abuse problems can be difficult. I want to be helpful to the whole family? may be useful: (Werner et al., p. 1110).
• Clinicians can support parents? recovery through the development of a nonjudgmental, honest, and supportive therapeutic relationship; making a plan for getting substance abuse treatment, supporting parents? attempts at and successes with recovery, and being an active member of the family?s recovery team are essential tasks of the clinician (Healthy Steps).
• Resources see CHADIS resource database):
• Twelve-step programs including Al-Anon, Alateen, and Adult Children of Alcoholics can be helpful for both the parent and family members.
• Therapists with expertise in working with families affected by substance abuse may be indicated
• Other services: detoxification programs, short-term residential programs, halfway houses, outpatient treatment programs, long-term residential programs, and sober houses (Healthy Steps).

References

1. Biederman, J., Faraone, S.V., Monuteaux, M.C., Feighner, J.A. (2000). Patterns of alcohol and drug use in adolescents can be predicted by parental substance use disorders. .
2. Bush, B., Shaw, S., Cleary, P., Delbanco, T.L., Aronson, M.D. (1987). Screening for alcohol abuse using the CAGE questionnaire. .
3. Ewing, J.E. (1984). Detecting alcoholism: the CAGE questionnaire. .
4. Kemper, K.J., Babonis, T.R. (1992). Screening for maternal depression in pediatric clinics. .
5. Lester, B.M., Tronick, E.Z., LaGasse, L., Seifer, R., Bauer, C.R., Shankaran, S., et al. (2002). The Maternal Lifestyle Study: Effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. .
6. Miller, W.R., Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, 2nd edition.
7. Moss, H.B., Vanyukov, M., Majumder, P.P., Kirisci, L., Tarter, R.E. (1995). Prepubertal sons of substance abusers: Influences of parental and familial substance abuse on behavioral disposition, IQ, and school achievement. .
8. Shankaran, S., Das, A., Bauer, C.R., Bada, H.S., Lester, B., Wright, L.L., et al. (2004). Association between patterns of maternal substance use and infant birth weight, length, and head circumference. .
9. Wallace, J.M. (1999). The social ecology of addiction: Race, risk, and resilience. .
10. Werner, M.J., Joffe, A., Graham, A.V. (1999). Screening, early identification, and office-based intervention with children and youth living in substance-abusing families.. .