Received: 27 May 2022 Accepted: 22 November 2022

DOI: 10.1002/imhj.22040

RESEARCH ARTICLE

Parenting stress and competence among mothers of young

children with substance use disorders: The roles of trauma
and reflective functioning

Ruth Paris1 Anna L. Herriott2 Melissa Holt1

1 Boston University, Boston, USA

2 University
of Chicago, Chicago, USA
Correspondence
Ruth Paris, School of Social Work, Boston
University, 264 Bay State Road, Boston,
MA 02215, USA.
Email: rparis@bu.edu
Funding information
the U.S. Department of Health and
Human Services; Substance Abuse and
Mental Health Services Administration;
National Child Traumatic Stress Initiative
Abstract
Posttraumatic stress symptoms are prominent in the lives of parents of young
children with substance use disorders (SUD). Parenting experiences, particu-
larly stress and competence, impact parenting behaviors and concomitant child
growth and development. Factors that promote positive experiences of parenting,
such as parental reflective functioning (PRF), and protect the mother and child
from negative outcomes are crucial to understand to develop effective therapeu-
tic interventions. The current US study analyzed baseline data from a parenting
intervention evaluation to examine how length of substance misuse, PRF, and
trauma symptoms were associated with parenting stress and parenting sense
of competence among mothers in treatment for SUDs. Measures included the
Addiction Severity Index, PTSD Symptom Scale-Self Report, Parental Reflective
Functioning Questionnaire, Parenting Stress Index/Short Form, and Parenting
Sense of Competence Scale. The sample included 54 predominantly White moth-
ers with SUDs who had young children. Two multivariate regression analyses
found that (1) lower parental reflective functioning and higher posttraumatic
stress symptoms were associated with higher parenting stress, and (2) only higher
posttraumatic stress symptoms were associated with lower levels of parenting
sense of competence. Findings underscore the importance of addressing trauma
symptoms and PRF when aiming to improve parenting experiences for women
with an SUD.

KEYWORDS
parental reflective functioning, parenting, substance use disorder, trauma

1 INTRODUCTION delivery increased by over four times the rate of previ-

Substance misuse during pregnancy and early parenting
is an alarming and complicated public health crisis, as
both mothers and their children contend with multiple
obstacles to optimal health and wellness. Between 1999
and 2014, rates of opioid use disorder (OUD) at labor and
ous years (Haight et al., 2018). Further, rates of pregnant
women with OUD and co-occurring polysubstance use sig-
nificantly increased between 2014 and 2016 (Jarlenski et al.,
2020). As the opioid crisis has increased, numbers of chil-
dren involved in the child welfare system have risen as
well (Feder et al., 2019). Not surprisingly, the COVID-19

228 © 2023 Michigan Association for Infant Mental Health. wileyonlinelibrary.com/journal/imhj Infant Ment Health J. 2023;44:228–239.
PARIS et al.
Statement of Relevance
Many women in recovery from SUDs who are par-
enting young children have experienced extensive
trauma and exhibit posttraumatic stress symp-
toms, which greatly impact parenting capacities
and child development. The present US study
adds to the knowledge base pertaining to parent-
ing while in recovery by focusing on predictors
of two parenting experiences, stress, and com-
petence. Study findings highlight the importance
of interventions focusing beyond SUD treatment
on trauma and parental reflective functioning
to improve parenting capacities for vulnerable
mother-child dyads.
pandemic has further exacerbated challenges associated
with having an SUD and accessing treatment (White et al.,
2022).
The intersection of parenting and substance misuse or
substance use disorders (SUDs) is inherently complex as
it is known that parents with SUDs typically contend with
concerns beyond their substance misuse that affect their
parenting and their children. SUDs are often associated
with maternal stressors, like intimate partner violence,
mental health disorders, and trauma; whereas children are
at risk for negative cognitive, social, and physical outcomes
(Conradt, et al., 2019; Winklbaur et al., 2008). Studies
have underscored how factors such as stress, trauma,
and co-occurring mental health disorders affect parent-
ing capacities in the context of SUDs (e.g., Finger et al.,
2018; Hatzis et al., 2019; Rutherford & Mayes, 2017). Given
the importance of parenting practices on the growth and
development of young children, it is vital to understand
the nuances of how these factors interact. The purpose of
this study is to closely examine specific concerns relevant
to parents with SUDs and how they interact with parent-
ing capacities. More specifically, we utilized baseline data
from an evaluation study to examine how the length of sub-
stance misuse, parental reflective functioning, and trauma
symptoms were associated with parenting stress and par-
enting sense of competence among a group of mothers
participating in a therapeutic parenting intervention while
in treatment for SUDs.
1.1 Parenting in the context of SUDs
Substance use disorders do not exist in isolation; rather,
they develop in relation to a variety of risk factors, includ-
229
Key Findings
1. In a community sample of 54 mothers with
SUDs parenting young children (mean age = 34
months), higher maternal posttraumatic stress
symptoms and lower parental reflective func-
tioning were associated with higher parenting
stress.
2. In a parallel model with the same sample, only
higher maternal posttraumatic stress symp-
toms were associated with parenting compe-
tence. Both models accounted for substance
misuse.
3. Results suggest that interventions focusing on
trauma symptoms and parental reflective func-
tioning may improve parenting stress and/or
parenting competence for mothers in recovery
with young children.
ing cultural context, family and trauma history, and mental
health challenges among others (see e.g., Gottdiener, 2013).
Parenting and the parent-child relationship in the con-
text of SUDs are affected by the parent’s own interplay
of characteristics and background that include but are
not limited to, the substance misuse itself (e.g., Finger
et al., 2018; Hatzis et al., 2019). From a neurobiological
perspective, ongoing substance misuse weakens reward
circuits in the brain, thus rendering other pleasurable
experiences—for example, caring for an infant—less so
(Rutherford & Mayes, 2017). Ongoing substance misuse
reinforces itself and results in neurobiological changes
that can become permanent over time, informing relapse
behaviors (Feltenstein & See, 2008). Further, overall stress
plays a significant role in the motivation for ongoing
substance misuse (Feltenstein & See, 2008). Addition-
ally, stress responses to the infant’s cues, such as crying,
may induce cravings for substances in the same way
that substance use had previously been associated with
a coping mechanism for negative emotions (Rutherford
& Mayes, 2017). However, factors affecting parenting in
the context of SUDs are multi-faceted. Pregnant and par-
enting women with SUDs typically have family histories
of SUDs, extensive trauma histories, and relatively high
rates of mental health diagnoses (Kaltenbach, 2013). All
these risk factors may result in sub-optimal parenting
and difficult parent-child relationships (Kaltenbach, 2013),
although it is important to remember that not all people
with SUDs raising young children struggle with parent-
ing challenges. Furthermore, a small qualitative study of
pregnant and postpartum women in treatment for SUDs
230
found that participants described trying to protect their
babies from harm on their own by seeking out infor-
mation, increasing their health-promoting behaviors, and
decreasing use of alcohol and drugs, suggesting that preg-
nant women with SUDs are often motivated to protect
their babies from harm prior to treatment engagement
(Van Scoyoc et al., 2017).
Researchers have attempted to better understand rela-
tionships between parenting and a variety of risk factors
associated with SUDs, highlighting the complexity and
cumulative nature of issues that affect parenting and child
development (e.g., Conners et al., 2003; Nair et al., 2003).
One study found that children whose mothers had comor-
bid mental health diagnoses were at significantly greater
risk for the development of internalizing problems than
children whose mothers had SUDs without a comorbid
mental health diagnosis (Hser et al., 2015). Additionally,
children of mothers with histories of SUDs with family
problems were at greater risk for the development of exter-
nalizing behaviors—regardless of mothers’ mental health
diagnoses (Hser et al., 2015). Findings related to SUDs and
parenting suggest the need for interventions that address
the myriad factors that influence parenting for those with
SUDs and provide support for the parent, child, and their
relationship.
1.2 Parental reflective functioning
For parents with SUDs, the development of reflective func-
tioning is known to be particularly challenging (e.g., Pajulo
et al., 2012; Suchman et al., 2008). Parental reflective func-
tioning (PRF) is the ability to mentalize or recognize one’s
own mental states—thoughts, feelings, and desires—as
well as the mental states of one’s children (Fonagy & Tar-
get, 1997; Slade, 2005) and connect them with behaviors
or actions (Slade, 2005). A parent’s ability to mentalize,
or to hold the child’s experience and feelings in mind
is thought to be critical for a parent’s ability to interact
sensitively and appropriately with her child and for sub-
sequent attachment and child development (Slade, 2005).
Difficulties in PRF may present as parents lacking the
ability to recognize that their child has an internal world
that informs the child’s behaviors and actions (Rutherford
et al., 2015). In some cases, parents may assume nega-
tive attributions of their child’s behavior, such as thinking
the baby’s cries are an effort to bother the parent and
be unable to enter the subjective world of their child
(Luyten et al., 2017). This type of distorted or absent reflec-
tive capacity is known as pre-mentalizing and has been
associated with parents’ diminished ability to tolerate and
manage their child’s distress in such a way that it impedes
caregiving (Rostad & Whitaker, 2016; Rutherford et al.,
PARIS et al.
2015). Parents more reliant on pre-mentalizing, and many
women with SUDs are in this group (Håkansson et al.,
2018) have been shown to be less involved with their chil-
dren, less communicative, use less positive discipline, and
overall feel less satisfied with the parenting experience
(Rostad & Whitaker, 2016).
Higher PRF has been associated with optimal caregiv-
ing practices and the child’s secure attachment to his or
her parent, both of which facilitate better outcomes for the
child (e.g., Camoirano, 2017; Ensink et al., 2016; Fonagy
et al., 1991). It has also been suggested that PRF is of partic-
ular importance during infancy and early childhood, when
the child is highly dependent on the parent and displays
intense emotions, necessitating the responses of a parent
who is able to be more reflective of her own mental states
and her child’s (Ensink et al., 2018).
The ability to form a secure attachment with their
child is often complicated for parents with SUDs and
may be related to compromised PRF or pre-mentalizing
(Håkansson et al., 2018). These parents may have difficul-
ties remaining emotionally connected and being sensitive
and responsive to their child in a way that emphasizes
his or her needs (Pajulo et al., 2012). As recent studies
have indicated, parents with SUDs may have parenting dif-
ficulties related to environmental and other risks, rather
than the substance misuse itself (e.g., Finger et al., 2018;
Hatzis et al., 2019). However, given the myriad associated
risks and concerns, children of parents with SUDs who
show less warmth and sensitivity to their child are more
likely to develop internalizing behavior problems, as well
as externalizing behavior problems due to the concomi-
tant higher levels of maternal harshness (Finger et al.,
2018). These difficulties—harshness and lack of warmth
and sensitivity—can impede the attachment relationship.
1.3 Substance use, trauma, and
parenting
Previous research has shown a significant relationship
between trauma—including childhood maltreatment, vic-
timization, and adverse experiences—PTSD, and sub-
stance use (Bishop et al., 2017; Cerezo & Pérez-García,
2019; Reichert et al., 2021; Torchalla et al., 2012). While
there is still debate as to whether trauma and PTSD pre-
cede substance use and substance use disorder, vice versa,
or if the two originate simultaneously, there is strong evi-
dence supporting the self-medication hypothesis wherein
individuals use substances to cope with the psychologi-
cal effects of traumatic events (Haller & Chassin, 2014;
Hruska & Delahanty, 2014). Regarding parents with SUDs,
Meulewaeter et al. (2019) found that the mothers in their
qualitative study all turned to substances as a form of
PARIS et al.
self-soothing in response to prior traumatic experiences.
Furthermore, their findings demonstrated ways in which
intergenerational trauma transmission disrupted attach-
ment between the mother and child (Meulewaeter et al.,
2019).
Even in the absence of SUDs, trauma can greatly affect
parenting processes and the parent-child relationship (e.g.,
Cross et al., 2018; Juul et al., 2016; Zvara et al., 2017).
For example, maternal trauma histories and diagnoses of
post-traumatic stress disorder (PTSD) have been associ-
ated with the potential of future child abuse (e.g., Cohen
et al., 2008; Cross et al., 2018; Smith et al., 2014), height-
ened anger and difficulties with emotion regulation in
parenting (e.g., Cohen et al., 2008; Smith et al., 2014),
and sub-optimal parent-child relationships (e.g., Muzik
et al., 2013; Reid-Cunningham, 2009; Riva Crugnola et al.,
2019). Furthermore, two systematic reviews, one exam-
ining the impact of history of maternal child abuse on
parent-child interactions (Vaillancourt et al., 2017) and the
second assessing the impact of parental trauma histories
and PTSD on the parent-child relationship and child devel-
opment (Van Ee et al., 2016), found negative effects of
parent history on caregiving behavior. The second review
also reported that the children in the dyads tended to be
more dysregulated and more easily distressed.
1.4 Parenting stress and competence
Parenting stress is viewed as an essential factor that
influences parenting behavior and, therefore, child well-
being (Abidin, 1992). Stress that is unique to parents is
thought to stem from how they see themselves as parents—
influenced by their own early attachment relationships—
and the number of resources they have at their disposal
to fulfill that parenting role and to meet the demands of
parenting (Abidin, 1992). Variables such as lack of social
support, negative perception of the child, and challenging
life events have been shown to increase parenting stress
(Östberg & Hagekull, 2000). Increased levels of parent-
ing stress have also been associated with high levels of
PTSD and psychological distress (Pinto et al., 2016). Par-
enting stress has been associated with increased risk for
child maltreatment, decreased sensitivity to children, and
child behavioral problems (Neece et al., 2012; Suchman &
Luthar, 2001; Taylor et al., 2009).
Similar to parenting stress, a parent’s sense of com-
petence also influences parenting behaviors (Johnston &
Mash, 1989). Parenting competence is constructed as a
combination of a parent’s sense of self-efficacy, or their per-
ception of their ability to handle parenting, and their sat-
isfaction with parenting (Johnston & Mash, 1989). Lower
levels of parenting competence have been associated with
231
higher rates of child behavior problems, more psycholog-
ical distress, and less social support (Johnston & Mash,
1989; Martinez-Torteya et al., 2018; Silver et al., 2006).
Additionally, improvements in parenting competence have
been associated with positive changes in parenting behav-
ior, highlighting it as a worthwhile target for intervention
(Deković et al., 2010).
1.4.1 The present study
While there has been increasing research on parenting in
the context of SUDs and trauma, as well as on parenting
capacities including PRF, parenting stress, and compe-
tence, we are not aware of any studies that have examined
these factors together. Considering the existing research,
the present study sought to understand the relationships
among substance misuse, trauma, and PRF in a sample
of women with young children in treatment for SUDs
who were seriously traumatized. Utilizing baseline data
from an academic-community partnership evaluating a
trauma-responsive, attachment-focused intervention, we
examined how length of substance misuse, PRF, and
trauma symptoms were associated with parenting stress
and parenting sense of competence. Given the limited
understanding of these relationships with the outcome
variables no hypotheses were proposed.
2 METHOD
2.1 Project BRIGHT II intervention
To understand the context within which the data were
collected, it is helpful to briefly review the intervention
that was offered, although this paper does not report post-
treatment findings from the evaluation. Project BRIGHT
II built on lessons learned from Project BRIGHT I (Build-
ing Resilience through Intervention: Growing Healthier
Together) (Paris et al., 2015, 2018) by offering a dyadic
attachment-focused intervention developed to address
traumatic stress in children ages birth to 6 years and their
parents who were in treatment for SUDs and co-occurring
disorders (CODs). The foci of the intervention included
improving: (a) parent-child relationships and parenting
capacities, (b) maternal mental health, and (c) young chil-
dren’s social-emotional development. Project BRIGHT II
provided an enhancement to treatment for SUDs, specif-
ically for parents receiving medications for opioid use
disorder (MOUD, e.g., methadone) and counseling at opi-
oid treatment programs (OTPs). Intervention sites were
three OTPs located in one New England state, chosen
specifically to address service gaps including a lack of
232
trauma-informed parenting initiatives and programs that
work with mothers and their young children.
2.2 Procedures
All parent participants were receiving treatment for SUD
at one of three area OTPs, parenting children ages birth to
6 years, and participating in the BRIGHT II intervention.
Questionnaires were administered to study participants at
the beginning of BRIGHT II treatment to assess parental
substance misuse history, trauma history, trauma symp-
tomatology, PRF, parenting stress, and parenting sense of
competence. Participants were consented to participate in
the evaluation by trained research assistants, who also
administered the baseline measures over the course of one
or two research visits at the start of treatment. Human
Subjects Protection approval was obtained from the first
author’s university Institutional Review Board.
2.3 Measures
2.3.1 Parental substance misuse history
Select sections of the Addiction Severity Index (ASI;
McLellan et al., 1992) were used to assess parents’ sub-
stance misuse. Overall, the ASI measures lifetime drug
use and recent (past 30 days) use, most frequent route
of administration, history of treatment for drug and alco-
hol use disorders, and other pertinent factors. The ASI
has demonstrated good reliability and validity, as well
as usefulness in assessing diverse populations, including
pregnant women with addiction (Argeriou et al., 1994;
McDermott et al., 1996). Lifetime use of heroin was used
as the measure of substance misuse as the majority of par-
ticipants had an opioid use disorder and were receiving
medication treatment.
2.3.2 Parental trauma history
The Life Stressor Checklist—Revised (LSC-R; Wolfe &
Kimerling, 1997) measures the occurrence or witnessing
of different types of traumatic events throughout an indi-
vidual’s life. This instrument was collected as part of the
evaluation but not used in this study’s analyses. The LSC-
R contains 27 items that are scored as 1(yes) or 0 (no) and if
endorsed, the age of the incident is recorded. Higher scores
on the LSC-R indicate greater levels of life stressors and
cumulative trauma. The LSC-R has good criterion validity
and test-retest reliability (Wolfe & Kimerling, 1997).
PARIS et al.
2.3.3 Parental trauma symptomatology
The PTSD Symptom Scale-Self Report (PSS-SR; Foa et al.,
1993), a 17-item self-report measure, assesses PTSD symp-
tomatology based on the DSM-III-R. The three clusters
of PTSD symptoms assessed included re-experiencing,
avoidance, and arousal. The PSS-SR has strong test-retest
reliability and good concurrent validity (Foa et al., 1993).
The Cronbach’s alpha in this sample for the PSS-SR was
excellent at .93.
2.3.4 Parental reflective functioning (PRF)
The Parental Reflective Functioning Questionnaire
(PRFQ; Luyten et al., 2009, 2017) is comprised of three
subscales (18 items total; six items per subscale): Interest
and Curiosity (IC), Pre-Mentalizing (PM), and Certainty
of Mental States (CM). The items are scored on a 7-point
scale from 1 (strongly disagree) to 7 (strongly agree). Assess-
ment of overall PRF for parents with SUDs typically report
low total scores in the pre-mentalizing range (Pajulo et al.,
2012; Suchman et al., 2017). Thus, the PRFQ PM subscale
was used for this study. Higher scores on the PRFQ PM
subscale indicate more pre-mentalizing (i.e., lower reflec-
tive functioning). A factor analysis of the 6-item PRFQ PM
subscale with this sample warranted the removal of one
item because it failed to meet the minimum factor loading
of .4. The revised 5-item PM scale used in the present
analysis had a moderate Cronbach’s alpha of .62 for this
sample.
2.3.5 Parenting stress
The Parenting Stress Index/Short Form (PSI/SF; Abidin,
1995) is a 36-item self-report measure assessing parent-
ing stress in three domains: parental distress, parent-child
dysfunctional interaction, and difficult child. The total
stress score was used for the present analysis; a high total
stress score indicates a greater level of parenting stress.
The PSI/SF has demonstrated good reliability and external
validity (Abidin, 1995). Cronbach’s alpha in this sample for
the PSI total score was excellent at .93.
2.3.6 Parenting sense of competence
The Parenting Sense of Competence Scale (PSOC; John-
ston & Mash, 1989), is a 16-item measure of parental
self-esteem. The PSOC consists of two scales—satisfaction
and efficacy, rated on a 6-point Likert scale from strongly
PARIS et al.
agree to strongly disagree. In a non-clinical sample of 586
mothers, the PSOC showed acceptable internal consis-
tency, with alphas ranging from .68 to .75 on the total score
and two subscales (Gilmore & Cuskelly, 2009). The Cron-
bach’s alpha in this sample for the PSOC total score was
.82, suggesting good internal consistency.
2.4 Data analysis
SPSS Statistics Version 20 was used for all data analysis.
First, frequencies and means were derived for demo-
graphic variables. Next, descriptive statistics (i.e., fre-
quencies and means) were run for measures assessing
substance misuse, PRF, trauma, potential PTSD, parenting
stress, and parenting confidence, and bivariate Spear-
man correlations among all study variables were com-
puted. Finally, to address our research questions regarding
associations between independent (i.e., heroin use, age,
pre-mentalizing, and trauma) and dependent variables,
two sets of regression analyses were run, one predicting
parenting stress and one predicting parenting sense of
competence. In each model variables were added sequen-
tially based on theoretical considerations to determine
their relative impact on parenting stress and competence.
In both cases, length of heroin use was entered first
given both strong documented associations with parenting
competence and hypothesized associations with parent-
ing stress, followed by parent age (as a control variable
for length of heroin use) in the second step. In the third
step, PRFQ pre-mentalizing scores were entered in order to
understand its unique association to both outcomes after
controlling for heroin use. Last, PSS scores were entered,
to determine contributions of trauma symptoms above
and beyond the other variables. Given the cross-sectional
nature of the data, mediational analyses were not run.
3 RESULTS
3.1 Sample
This study utilized baseline data collected from N = 54 par-
ents with young children who participated in the BRIGHT
II intervention and enrolled in the evaluation between
2012 and 2016. All participants identified as female, the
mean age was 31.35 (SD = 8.07; Range 21–58 years) and
the majority (64.8%) were never married. Most (98.1%)
indicated they identified as White, non-Hispanic, reflect-
ing the majority of women seeking treatment at OTPs in
the particular region. Women reported a range of edu-
cational backgrounds; the largest group (31.5%) indicated
their highest level of education completed was 12th grade
233
or a high school diploma equivalent. The majority of
women were unemployed—31.5% were unemployed and
not looking for work, 25.9% were unemployed and looking
for work, and 14.8% were unemployed due to a disability.
Approximately half (51.9%) of the women had one child,
14.8% had two children, 22.2% had three children, 7.4% had
four children, 1.9% had five children, and 1.9% had eleven
children. The average age for children was 34.35 months
(SD = 28.75; Range 1.08–96.96 months). The majority of
women (88.9%) had been involved with the state child wel-
fare agency (Department of Children and Families, DCF)
previously, ranging from one time (58.3%) to four times
(2.1%).
3.2 Preliminary analyses
LSC-R scores, which reflect trauma exposures among
the mothers, averaged 12.48 (SD = 5.64) discrete events
(e.g., family member’s substance misuse, family mem-
ber’s incarceration, serious financial problems, emo-
tional/physical abuse, abortion/stillbirth/miscarriage, wit-
nessing violence as a child). With respect to substance
misuse, 61.1% of the sample reported heroin use, fol-
lowed by poly-drug use which included opioids (18.5%) and
other opioids/analgesics use (14.8%). Methamphetamine
use, using more than one substance per day, and dual
addiction were each reported by one mother. Based on PSS
scores, results indicated that 68.5% of the mothers met the
cut-off for being at risk for PTSD. With respect to parenting
stress levels (PSI), half the sample were below risk status,
27.8% were at risk, and 22.2% were classified as high stress.
Nearly 4% of the sample (3.7%) reported low parental con-
fidence, 42.6% reported moderate parental confidence, and
53.7% reported high parental confidence.
As indicated in Table 1, parent age was not significantly
correlated with any study variables. Greater years of heroin
use was significantly correlated with lower parenting sense
of competence. Both positive and negative statistically sig-
nificant correlations were found between posttraumatic
stress symptoms (PSS) and: pre-mentalizing (positive),
parental stress (positive), and parenting sense of compe-
tence (negative). Parenting sense of competence was also
significantly negatively associated with pre-mentalizing
modes and parental stress. Finally, there was a signif-
icant positive association between parental stress and
pre-mentalizing modes.
3.3 Regression analyses
As shown in Table 2, neither heroin use nor parent age
were associated with parenting stress, but pre-mentalizing
234 PARIS et al.

T A B L E 1 Mothers’ reports of lifetime heroin use (months), age, trauma symptomology, pre-mentalizing modes, parental stress, and
parenting sense of competence: descriptive statistics and correlations (N = 54).
Variable M SD 1 2 3 4 5
1. Lifetime Heroin Use 58.35 52.71 _
2. Parent Age 31.35 8.08 .26 _
3. Adult Trauma Symptomology 20.23 13.08 .21 .07 _
4. Pre-Mentalizing Modes 1.63 .91 .01 .03 .41** _
5. Parental Stress 77.95 22.01 .21 .24 .50** .55** _
6. Parenting Sense of Competence 69.71 10.84 –.32* –.25 –.48** –.31* –.66**
*p < .05.
**p < .01.

TA B L E 2 Summary of hierarchical regression analysis for variables predicting parental stress (N = 54)
Model 1 Model 2 Model 3 Model 4
Variable B SEB β B SE B β B SE B β B SE B β
Lifetime Heroin Use .09 .06 .21 .07 .06 .16 .07 .05 .16 .04 .05 .10
Parent Age .56 .38 .20 .50 .31 .18 .49 .30 .18
Pre-Mentalizing Modes 13.20 2.70 .55** 10.30 2.80 .43**
Adult Trauma Symptomology .49 .20 .29*
2
R .05 .08 .38 .45
F for change in R2 2.44 2.30 10.31** 10.02**
*p < .05.
**p < .01.

TA B L E 3 Summary of hierarchical regression analysis for variables predicting parenting sense of competence (N = 54)
Model 1 Model 2 Model 3 Model 4
Variable B SE B β B SE B β B SE B β B SE B β
Lifetime Heroin Use –.07 .03 –.32* –.06 .03 –.27* –.06 .03 –.27* –.04 –.03 –.20
Parent Age –.24 .18 –.18 –.23 .17 –.17 –.23 .16 –.17
Pre-Mentalizing Modes –3.59 1.48 –.30* –1.85 1.53 –.16
Adult Trauma Symptomology –.30 .11 –.36**
R2 .10 .13 .22 .31
F for change in R2 5.85* 3.88* 4.80** 5.93**
*p < .05.
**p < .01.

scores were in the third step of the model. In addition,
the change in R2 between Models 2 and 3 was statistically
significant. Once PSS scores were added to the model in
the fourth step, pre-mentalizing maintained its significant
association, with PSS scores adding a significant contribu-
tion to understanding parenting stress. Notably, including
PSS scores in the model also improved the overall parental
stress model, demonstrated by a statistically significant
change in R2 . The final model demonstrated that difficul-
ties with PRF, or mentalizing about one’s child, and more
parental posttraumatic stress symptoms were both signifi-
cantly associated with higher levels of parenting stress for
mothers of young children with SUDs.
With respect to models demonstrating correlates of par-
enting sense of competence (see Table 3), length of heroin
use was significantly associated in the first, second, and
third steps of the model. Pre-mentalizing predicted parent-
ing competence in the third step, but when PSS scores were
entered in the fourth step pre-mentalizing was no longer
significantly associated. In contrast, PSS scores were asso-
ciated with parenting sense of competence. As indicated
in Table 3, adding variables to the regression model signif-
icantly improved the explained variance at each step. Here
the final model demonstrated that trauma symptomatol-
ogy was the only significant correlate of parenting sense of
competence, while ability to mentalize about one’s child
PARIS et al.
and heroin use were no longer directly associated with the
outcome variable.
4 DISCUSSION
The goal of this study was to examine the relationships
among parenting, substance misuse, PRF, and trauma
for women with SUDs who have young children. Specif-
ically, we were interested in factors that are associated
with experiences of parenting—such as stress and sense of
competence. As previous research has shown (Kaltenbach,
2013), substance misuse is not the only or most salient
factor contributing to parenting for mothers with SUDs.
Trauma history, current traumatic stressors, concomitant
neurobiological changes, and mental health challenges,
among other social and economic factors, can all play vital
roles in a woman’s parenting experiences (Finger et al.,
2018; Hatzis et al., 2019; Rutherford & Mayes, 2017).
The bivariate findings were notable in that length of
heroin use was significantly associated with a parent’s
sense of competence, but not with parenting stress. Length
of heroin use can indicate greater severity of an SUD
or traumas in life and possibly greater neuro-biological
complications (Rutherford & Mayes, 2017) making it an
important predictor of perceived parenting experiences.
Furthermore, extensive heroin use is often coupled with
a sense of failure as a parent as children may have been
removed by child welfare or cared for by a family mem-
ber while the parent was actively using, possibly explaining
its association with sense of competence as a parent but
not stress. Trauma symptomatology was associated with
parental stress, parenting sense of competence, and PRF in
the form of pre-mentalizing, as other studies have shown
(Cross et al., 2018; Juul et al., 2016). These initial findings
demonstrate that substance use on its own is not necessar-
ily the primary driver of parenting experiences for mothers
with SUDs, but underlying posttraumatic stress symptoms,
among other factors, are crucial to consider to under-
stand multifaceted mechanisms. The bivariate associations
serve as important starting points, but do not account
for the complexities of relational experiences, hence our
multivariate models better address these intricacies.
In the final multivariate model predicting parenting
stress, both lower PRF (more pre-mentalizing) and greater
maternal posttraumatic stress symptoms significantly con-
tributed to a mother’s parenting stress, but as shown in the
bivariate correlations length of heroin use did not. Parents
who rely on pre-mentalizing tend to show more distortions
in how they view their child and may be unable to see
the nuanced relationships between feelings, thoughts, and
behaviors. They are more likely to view their child through
their own specific lens and either misattribute behaviors
235
to incorrect assumptions (e.g., child is crying to indicate
the inadequacy of their mother) or not imagine that the
child has any particular feelings at all. These misattribu-
tions or distortions may leave more room for a mother
to feel stressed in her role as a parent, particularly if she
views the child’s crying, fussiness or difficulties eating as
challenging to manage and an indictment of her parenting
practices.
Posttraumatic stress symptoms are experienced by many
mothers with SUDs given their extensive trauma histories
and the stressors that are frequently part of their disorder.
Parental trauma history and symptomatology have been
shown to consistently impact parenting experiences and
practices (Cohen et al., 2008; Muzik et al., 2013; Smith
et al., 2014). The finding that trauma symptoms are pos-
itively associated with parenting stress is consistent with
previous studies. What is of note here is that the mother’s
posttraumatic stress symptoms play a significant role in
her experience of parenting stress and length of heroin use
does not. As discussed earlier, SUDs are complex in that
they are highly correlated with trauma histories, likely con-
tributing to the onset of substance misuse, and concurrent
traumatic experiences (e.g., interpersonal violence, hous-
ing insecurity, and food insecurity). From this analysis,
one can wonder if underlying trauma is more of a con-
tributing factor to parenting stress for women with SUDs
than substance misuse itself or if they are overlapping risks
(Kraemer et al., 2001). Although the measure of heroin use
in these analyses is length of time and not severity, longer
use can certainly be seen as significantly damaging to a
person’s life and parenting abilities.
With respect to the final model predicting parenting
sense of competence, only parents’ posttraumatic stress
symptoms were associated with the dependent variable;
neither length of heroin use nor the pre-mentalizing aspect
of PRF were significantly related. Parenting sense of com-
petence consequently may be reliant on factors such as
trauma symptoms that interfere with the actual parenting
process leading to a sense of inadequacy as a parent. Pre-
mentalizing is more of an internal process that relies on a
parent’s inability to attune to a young child’s mental states
but does not seem linked to parenting sense of competence
in this sample when trauma symptoms are present. The-
oretically, it is possible that in other populations higher
levels of aspects of PRF, (e.g., certainty of mental states or
interest and curiosity), could additionally contribute to the
impact of posttraumatic stress symptoms on this parenting
experience. Furthermore, parenting sense of competence
may rely heavily on the mother’s sense of accomplishment,
having less to do with the child in this instance, and thus
be more strongly associated with trauma symptoms such as
anxiety, re-experiencing, avoidance, or arousal which can
alter how a woman feels about her parenting abilities.
236
Notably, in both models—predicting parenting stress
and parenting sense of competence, the lifetime length
of heroin use was either not associated or was not the
most significant correlate of parenting capacities. While
these findings are drawn from a small sample of women,
we think it is important to underscore how the substance
misuse itself was not the factor that was most strongly
associated with parenting capacities, which is contrary
to how parents with SUDs tend to be portrayed in the
media and in cultural discourse (Paris et al., 2020). Such-
man consistently worked to disentangle the complexities
of the impact of substance use on parenting, often find-
ing overlapping or proxy risk factors. In one study she
found that parenting practices thought to be primarily
attributable to substance use were also linked to socioe-
conomic status (Suchman & Luthar, 2000) and in another
found that depression and substance use served as prox-
ies for absence of social support for mothers with SUDs
(Suchman et al., 2005). Although SUDs in the context
of parenting are gravely concerning, this study highlights
that trauma experiences and associated symptomatology
that typically co-occur with SUDs at high rates (Najavits,
2009) are significant correlates of parenting capacities and
hopefully offer an additional path for intervention.
4.1 Limitations
While the current study contributes to our understand-
ing of substance misuse, trauma and parenting, there are
several limitations. The sample size was small and com-
prised of a relatively homogeneous group of women who
were majority White, unmarried, primarily misused opi-
oids, and were participating in a therapeutic parenting
intervention. These facts may limit the generalizability of
the findings to other ethnic and racial groups of mothers
with SUDs, or those using other substances (e.g., metham-
phetamines), but they well represent many pregnant and
parenting women in various regions of the United States
where opioid misuse is occurring at epidemic levels, partic-
ularly during the COVID-19 pandemic (White et al., 2022).
The measure used to represent the severity of substance
misuse was length of time used, which was one way to
assess severity. We did not have access to data indicating
frequency or amount of use, which may have been better
predictors. These types of data are very difficult to obtain in
a study using self-report measures. The multivariate mod-
els attempt to address the complex relationships among
substance use, trauma, and parenting, however given the
concurrent nature of the data we chose not to conduct
mediational analyses which could further illuminate pos-
sible mechanisms at play in predicting perceived parenting
experiences.
PARIS et al.
4.2 Implications for clinical practice
and research
Findings from this study add to the growing body of
clinical literature addressing PRF and attachment (e.g.,
Riva Crugnola et al., 2021; Slade & Holmes, 2019), and
more specifically, parenting and substance misuse. The
importance of addressing posttraumatic stress symptoms
and developing trauma-responsive programs both within
SUD treatment and infant mental health interventions
are increasingly accepted (Dass-Brailsford & Myrick, 2010;
Lieberman, 2004). SUD treatment settings have been
slower to address parenting capacities as a central part
of recovery for mothers with young children. These
findings point to the complexity of perceived parenting
experiences, such as stress and competence, and sug-
gest the importance of concurrently addressing trauma
symptoms and PRF while supporting recovery to promote
optimal parenting. One way the BRIGHT intervention
directly addresses trauma is by attending to emotional
triggers and dysregulation while parenting which are fre-
quently associated with trauma histories and symptoms.
Although addressing triggers are typically an aspect of
SUD treatment, mentalization-based therapies that aim
to boost PRF for parents who misuse substances should
adopt more of this focus as well to improve parenting
capacities.
Promoting optimal PRF and minimizing pre-
mentalizing for mothers may mitigate parenting stress
and improve parenting practices. Suchman et al. found
repeated evidence that a mentalization-based thera-
peutic parenting intervention focused on improving
PRF improved maternal caregiving representations and
behaviors (Suchman et al., 2008, 2017, 2018). Suchman’s
groundbreaking work has moved the field forward such
that numerous researchers and practitioners have incor-
porated a focus on PRF as a key mechanism of change
when working with parents in a variety of SUD treat-
ment settings (Bosk et al., 2019). However, there is still
much work to be done to integrate mentalization-based
approaches within substance use treatment (Suchman
et al., 2020).
Future research could build on these findings by work-
ing to illuminate aspects of the parenting experience
impacted by PRF with ethnically and racially diverse
people with SUDs to inform relevant intervention develop-
ment. Pathways of change should continue to be examined
in longitudinal studies which test the implementation of
mentalization-based treatments for parents in recovery,
building on the work of Suchman et al. Findings from these
types of studies will assist us in our ability to help both
parents and young children challenged by the devastating
impact of substance misuse and trauma.
PARIS et al.
AC K N OW L E D G M E N T S
This study was supported by grant # U79SM059460 (PI,
Norma Finkelstein) from the U.S. Department of Health
and Human Services, Substance Abuse and Mental Health
Services Administration, National Child Traumatic Stress
Initiative. The authors acknowledge the leadership, par-
ticipation, and support of our community partners, Karen
Gould, Susan O’Donnell, and Amy Sommer and the
BRIGHT clinicians at the Institute for Health and Recov-
ery and Jewish Family and Children’s Service. We also
wish to acknowledge the work and friendship of Nancy
Suchman who inspired many aspects of our research pro-
gram and generously engaged in thoughtful and complex
conversations over the years.
C O N F L I C T O F I N T E R E S T S TAT E M E N T
Ruth Paris, Anna Herriott, and Melissa Holt declare that
they have no conflict of interests associated with the
publication of this paper.
H U M A N S U B J E C T S A P P R O VA L
Boston University, Institutional Review Board, Protocol
#3134E.
D A T A AVA I L A B I L I T Y S T A T E M E N T
The data that support the findings of this study are
available from the corresponding author upon reasonable
request. The data are not publicly available due to privacy
or ethical restrictions.
ORCID
Ruth Paris https://orcid.org/0000-0002-3151-9070
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