Luz S.PorterPhD, ARNP, FAANP, FAAN 1 Brian O.PorterMD, PhD, MPH 2 VirginiaMcCoyPhD 3 VivianBango-SanchezEdD, ARNP 4 BonnieKisselEdD, ARNP 4 MarjorieWilliamsDNP, ARNP, FNP-BC 5 SachinNunnewarMD, MPH6
1 College of Nursing and Health Sciences, Florida International University, Miami, FL, USA
2 External IMPEP Study Co-Investigator, University of Miami, Miami, FL, USA
3 Department of Health Promotion and Disease Prevention, Robert Stemple School of Public Health, Florida International University, Miami, FL, USA
4 Memorial Regional Hospital, Hollywood, FL, USA
5 AIDS Healthcare Foundation, Miami Beach, FL, USA
6 IMPEP Study Team, Robert Stemple School of Public Health, Florida International University, Miami, FL, USA
At the height of public health concern in the 1990s, U.S. health agencies estimated nearly 4.6 million women of childbearing age regularly used cocaine, with drug-exposed births rising from 300,000 in 1992 to 750,000 in 1995 1, 2, 3. Given the myriad of negative life events (e.g., domestic violence, sexually transmitted infections) experienced by substance-abusing mothers (SAMs) even when in recovery, SAMs are vulnerable to mental health problems including parenting stress, depression, low self-esteem, and deviant maternal attachment . The purpose of this study was to evaluate the effects of a blended Infant Massage–Parenting Enhancement Program (IMPEP) on mental health outcomes among recovering SAMs.
Parenting stress (i.e., feeling unduly pressured by infant care and the parenting role) can negatively impact child development, either directly or indirectly through parenting behaviors 5, 6. For recovering SAMs, self-consciousness over a history of incarceration, mandated rehabilitation programs, and vulnerability to recidivism may impair the ability to cope with the stresses of parenting related not only to the need to care for their infants but also to the need to satisfy intense cravings created by their substance addiction .
Depression is also a recognized risk factor for drug and alcohol addiction 8, 9, as more than one-third of females using drugs having had a major depressive episode. Depression develops most frequently in people's twenties , which corresponds to the period of greatest fertility. An estimated 10%–20% of women struggle with major depression before, during, or after childbirth . Women who are of lower socioeconomic status, less educated, unemployed, and from ethnic/racial minority populations are more likely to experience depression 12, 13, 14. Thus, risk factors associated with both depression and maternal substance abuse contribute to a vicious cycle for recovering SAMs, with their infants being at increased risk of developing insecure attachments, negative affect, and dysregulated attention and arousal .
Potentially serving as a counterbalance to these negative psychologic states, self-esteem is the disposition to experience oneself as competent to cope with basic life challenges and worthy of happiness . Self-esteem is influenced by both environmental and psychological factors 17, 18, with low self-esteem leading to dysfunctional relationships, neurosis, anxiety, and depression, acting as a universal denominator in addiction . Positive self-esteem can serve as a buffer from anxiety, guilt, shame, criticism and depression, thereby promoting mother-infant interaction.
Developmental theorists assert the most important task of an infant's life is to establish basic trust and security in others 20, 21. Attachment involves a reciprocal, interactive system between mother and infant in which both individuals are active participants, with infants evoking responses from adults who are sensitive and committed to observe, understand, and respond appropriately to cues. Attachments vary in quality from secure to anxious and may be thwarted by risk factors such as poverty, mental illness, maternal substance abuse, and lack of social support 20, 22. In the case of SAMs, mother-infant interactions are at risk due to the mother's guilt, poor self-image, and lack of parenting confidence , as well as the infant's impaired ability to send clear cues and respond favorably to the mother.
Multidimensional intervention programs have been tested on both SAMs and depressed mothers to improve parenting skills and prevent negative sequelae such as child abuse 24, 25. However, these studies did not incorporate infant massage as a key modality. Practiced in many countries for centuries, infant massage is reflective of different cultural practices involving physical touch to communicate warmth and gentleness to the infant .
Individual trials have suggested the benefits of infant massage for mother-infant bonding and infant health outcomes, including protection against infection, weight gain in both preterm and full-term infants, improvements on the Bayley Infant Scales of Mental and Motor Development, and increased bone mineral density 27, 28, 29, 30. However, more recent studies  and a Cochrane review  of 34 randomized infant massage trials did not confirm statistically significant improvements in infant measures of physical and mental development. As this metaanalysis was focused on low-risk groups of parents and infants, its findings may not generalize to SAMs and their infants. In turn, another recent metaanalysis confirmed infant massage led to statistically significant improvements in daily weight gain in preterm infants and reduced their length of hospital stay .
To date, infant massage has been applied primarily in hospital settings, with most controlled studies focused only on infant health outcomes. However, infant massage holds the promise of improving mental health outcomes in high-risk mothers as well, as studies have suggested infant massage may improve mother-infant interaction in mothers with postpartum depression 34, 35 and decrease depressive symptoms in mothers of preterm infants .
Purpose of study
This study was conducted to evaluate the effects of infant massage integrated into a structured multidimensional parenting enhancement program (PEP) on key mental health outcomes among recovering SAMs. We hypothesized that compared to a PEP intervention without infant massage or standard of care parenting education, the IMPEP will decrease parenting stress and depression in recovering SAMs, while improving self-esteem, maternal attachment, and mother-infant interaction.
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The results of this study demonstrated the value-added effects of infant massage blended into a systematic parenting skills program on reducing parenting stress and maternal depressive symptoms; although a similar impact on self-esteem, maternal attachment, and mother-infant interaction was not demonstrated. Despite the infant massage component of the IMPEP not demonstrating consistent value-added effects across all the psychosocial dimensions examined in this study, the potential impact of the IMPEP is high with respect to parent-child health promotion, as studies implementing this intervention hold great promise for expanding the knowledge base of health enhancement among at-risk populations. The present findings related to depression and the psychosocial dimension of parenting stress corroborate previous studies with respect to the positive health impact of touch, reinforcing the use of the IMPEP as both a health promotion intervention and therapeutic tool by nurse educators, maternal-child health practitioners, and substance abuse service providers.
With respect to further longitudinal study of SAMs to assess the long-term impact of the IMPEP, it may be unrealistic to expect consistent follow-up beyond 3 months, given the attrition rates observed in this study past Week 12. However, the IMPEP may be tested further in other vulnerable populations to validate its effects within different cultural contexts. A cross-sectional study is a feasible design to determine whether differences in outcomes among the IMPEP, PEP, and Control groups persist across different age groups of mothers and children. A mixed research design merits consideration for future studies to gain greater insights into the myriad problems confronting recovering SAMs. The primary limitation of this study was participant attrition which decreased the final sample size and limited the study's power. An imbalance in dropout rates resulted in the IMPEP group being notably larger than both the PEP and Control groups, potentially limiting the ability of the randomized, controlled design to fully account for systematic biases or confounding variables.