#2&3Notes on Accelerating the Pace of Science: Interventions for Parents with Opioid Use Disorder

Overview

Public health emergency in the United States due to rising overdose deaths related to Opioid Use Disorder (OUD).
Rise in the number of children exposed to parents with an OUD; urgent need for parenting interventions targeting this population.
Conventional, linear progression from basic science to program implementation is slow; prior research suggests moving from basic science to real-world impact can take about 17\,\text{years}.
Authors propose four strategies to accelerate the pace of science so parenting practices for parents with OUD improve more quickly.
Goal: provide a roadmap for researchers and practitioners to deliver timely, evidence-based interventions to families affected by OUD.

Key epidemiological context and motivation

October 2017: U.S. Department of Health and Human Services declared a public health emergency to address rising overdose deaths related to OUD. This public health emergency also increases the number of children exposed to parental OUD.
Prevalence data (OUD among women delivering): from 1.5/1000\text{ deliveries} in 1999 to 6.5/1000\text{ deliveries} by 2014, a greater than fourfold increase (Haight, Ko, Tong, Bohm, & Callaghan, 2018).
Neonatal outcomes: NAS/NOWS (Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome) increased 300% over the period, with NAS/NOWS hospital birth rates rising from 1.5/1000\text{ hospital births} in 1999 to 6.0/1000\text{ hospital births} in 2013 (Ko et al., 2016).
Child welfare: NAS/NOWS reports rose from 4.72% of child welfare reports in 2004 to 9.19% in 2014 (Lynch, Sherman, Snyder, & Mattson, 2018).
Importantly, opioid cessation alone does not reliably improve parenting; parent-training and environmental supports are needed (Suchman, Decoste, McMahon, Rounsaville, & Mayes, 2011).
These data underscore the need for scalable, evidence-based parenting interventions for parents with OUD and rapid translation into practice.
The authors’ aims: (1) identify malleable intervention targets and implementation considerations for parents with OUD; (2) propose methods and interventions to accelerate the pace of science so evidence-based parenting supports reach families more rapidly.

Theoretical foundations and frameworks

Bronfenbrenner’s Ecological Theory (1979, 1994): development is shaped by interactions across nested systems:
- Microsystem: individual’s immediate environment (e.g., family, partner, peers).
- Mesosystem: interactions between microsystems (e.g., parent–child interactions, family interactions).
- Exosystem: external settings that indirectly affect the individual (e.g., workplaces, services).
- Macrosystem: broader cultural beliefs, values, and policies.
- Chronosystem: temporal dynamics and transitions over the life course.
NIH Stage Model for behavioral interventions (Onken et al., 2014): six stages of intervention development and implementation:
- Stage 0: basic research
- Stage 1: intervention generation and refinement
- Stage 2: efficacy testing in research clinics
- Stage 3: efficacy testing in community clinics
- Stage 4: effectiveness testing
- Stage 5: implementation and dissemination
- Note: stages are not always linear, and not all stages must be completed, but the model helps plan work and communication.
The authors advocate a transdiagnostic approach: leverage interventions already developed for other populations by targeting shared mechanisms and using scalable implementation strategies.
They propose integrating the NIH Stage Model with ecological theory to identify intervention targets and implementation considerations for parents with OUD and to accelerate adoption in real-world settings.

Goals of the review and roadmap

Goal 1: Review extant literature to identify malleable intervention targets and implementation considerations pertinent to parents with OUD.
Goal 2: Propose concrete methods and interventions to accelerate the pace of science by leveraging identified targets and implementation factors, enabling rapid, wide dissemination of effective parenting supports.
Deliver a roadmap for researchers and practitioners to adapt, test, and implement evidence-based parenting interventions for parents with OUD.
Clarify definitions:
- “Parents”: individuals actively parenting their child(ren) in-home or in residential treatment settings.
- “Parents with OUD”: parents who may not have a formal OUD diagnosis but exhibit opioid misuse along the spectrum of disordered use (tolerance/withdrawal, impaired control, etc.).
Contextual note: the article builds on related work in other substance use disorders and comorbid conditions (e.g., trauma, mental health disorders).

Key targets and mechanisms identified through the ecological lens

Individual considerations for identifying intervention targets

Individuals with OUD show higher prevalence of personality disorders, especially cluster B (antisocial, borderline) (Barry et al., 2016; Hans, Bernstein, & Henson, 1999).
Greater likelihood of co-occurring anxiety and depression and other SUDs (Grattan et al., 2012; Hans et al., 1999; Brooner et al., 1997; Kidorf et al., 2018).
Emotion regulation difficulties are common and may be bidirectional with OUD: emotion regulation can be a precursor to use and also an outcome of use/withdrawal (Wolff et al., 2016; Wilens et al., 2013; Wilson et al., 2017; Tang et al., 2015).
Parenting beliefs and knowledge gaps: inappropriate child expectations, reversed parent–child roles, corporal punishment, low empathy, and lack of basic parenting information (illness signs, nutrition, infant development) (Rizzo et al., 2014; Butz et al., 1998).
Maternal styles: somewhat reduced sensitivity and warmth among OUD-affected mothers; adolescents and infants show less optimal dyadic interactions when maternal distress or unmanaged opioid use is present (Salo et al., 2009; Salo et al., 2010; Sarfi et al., 2011).
Gender differences:
- Fathers with OUD more likely to live apart from children; when involved, demonstrate reduced positive parenting and satisfaction (McMahon, Winkel, & Rounsaville, 2005).
- Women with OUD are more likely to begin use via prescription, to have health problems, unemployment, and childcare responsibilities; treatment entry is often motivated by pregnancy or custody concerns (Bawor et al., 2015; McMahon et al., 2002).
Prenatal exposure vs. postnatal parenting: NAS/NOWS concerns are prominent during pregnancy, but later child outcomes are more strongly linked to parenting quality and environmental context than prenatal opioid exposure alone (Lowe et al., 2017; Kaltenbach et al., 2018; Logan et al., 2014).
Adverse childhood experiences (ACEs) in parents and their relation to parenting: higher ACEs relate to parenting challenges and can moderate intervention effects (Shaw et al., 2009; Gannon et al., 2017).
Implications for intervention design: interventions should target emotion regulation, parenting knowledge, support for caregiving, and reduction of parenting-related stress in the context of OUD.

Microsystem considerations for intervention targets

Interactions within the family and close social networks (partner/family support) influence readiness to change and treatment engagement (Suchman et al., 2010; Fulmer & Stout, 2015).
Social support is protective: more supportive families and partners in treatment are associated with abstinence and improved relationships; limited social support is linked to higher comorbid depression and opioid use (Suchman et al., 2010; Fulmer & Stout, 2015).
Interparental conflict and lack of parenting support when partners separate can undermine parenting outcomes (Spehr et al., 2017).
Parenting in the context of OUD is associated with: reduced maternal sensitivity, lower non-intrusiveness, and lower parental involvement relative to peers with similar SES but no substance use (Salo et al., 2009; Salo et al., 2010; Suchman & Luthar, 2000).
Environmental risk factors in the microsystem (e.g., supervision gaps, exposure to illegal activities and unsafe adults) can directly affect child development (Powis et al., 2000).

Other considerations for intervention targets

OUD often co-occurs with other disorders and life stressors; cumulative risk can overwhelm parenting (Austin & Shanahan, 2017; McCabe et al., 2008; Peisch et al., 2018).
The broader environmental context (poverty, housing instability, access to healthcare) shapes parenting opportunities and intervention feasibility.
The relationship between prenatal exposure and later child outcomes is complex; maternal psychological distress and parenting quality can be more predictive of child behavior than prenatal opioid exposure alone (Sarfi et al., 2013; Mayes & Bornstein, 1995, 1997).

Exosystem, macrosystem, and chronosystem considerations for implementation

Stigma: substantial barrier in the macrosystem for pregnant/postpartum women with substance use, affecting care seeking and parenting decisions (Howell & Chasnoff, 1999; Stone, 2015).
Employment and socioeconomic barriers: women with SUDs often face limited employment opportunities due to education, job skills, and stigma; this affects family functioning and treatment access (Bowden & Goodman, 2015).
Child welfare involvement: higher likelihood of child protective services involvement historically for parents with OUD; about half of their children remain in parental custody in some samples, underscoring the need for integrated parenting supports within child welfare systems (Taplin & Mattick, 2015).
Healthcare system gaps: need for training pediatric trainees to discuss addiction and trauma while managing NAS; routine care for pregnant/parenting women with SUD should include family-focused approaches (Schiff et al., 2017; Rutherford, Berry, & Mayes, 2018).
Chronosystem perspective: history of home instability and attachment difficulties can be transmitted across generations; intergenerational patterns of trauma and parenting challenges highlight the importance of breaking cycles through interventions (Cerdá et al., 2014; Cohen, Hien, & Batchelder, 2008; Yehuda & Lehrner, 2018).

Accelerating the pace of science: four strategic approaches

Strategy A: Adapt existing efficacious/effective parenting interventions for parents with OUD (Stage 1). Examples include:
- Pre- and post-natal home visiting programs (e.g., HANDS; Nurse-Family Partnership) that could be enhanced with opioid-use-specific guidance and NAS/NOWS care components (Klaman et al., 2017; Olds, 2002; Williams et al., 2017).
- Preschool-to-adolescent programs (PCIT; FCU) adapted for parents with OUD, including on-site delivery in residential treatment or drug-treatment facilities; on-site therapists and staff training would be required (Chaffin et al., 2004; Dishion et al., 2014; Shaw et al., 2009).
Strategy B: Oversample parents with OUD in efficacy/effectiveness trials (Stages 2–4) to test moderation by opioid use and identify relevant moderators and mechanisms (Powell, 2013).
- Examples: Mothering from the Inside Out (MIO) pilot trials and ongoing RCTs across SUDs; Multisystemic Therapy–Building Stronger Families (MST-BSF) with SUD parents (Suchman et al., 2010; Schaeffer et al., 2013; Zajac, Randall, & Swenson, 2015).
- Goals: determine whether effects hold for parents with OUD, examine moderator/mediator effects, and compare OUD vs non-OUD groups.
- Pilot results suggest MST-BSF can reduce youth anxiety, decrease maternal drug use, reduce depressive symptoms, and lower new substantiated maltreatment cases compared with standard care (Schaeffer et al., 2013).
Strategy C: Test existing interventions specifically for parents with OUD in effectiveness trials (Stage 4) and study implementation outcomes (hybrid designs). Examples:
- Parents Under Pressure (PUP): home-based program with parenting skills and mindfulness to improve emotion regulation and relapse prevention; reports reductions in child abuse potential, rigid parenting attitudes, and child behavior problems at 3- and 6-month follow-ups (Dawe & Harnett, 2007).
- Relational Psychotherapy Mothers’ Group (RPMG): 24-week group-based psychotherapy including methadone counseling; associated with reduced child abuse potential, greater involvement with children, and improved maternal psychosocial functioning; also showed reductions in opioid use over time (Luthar & Suchman, 2000; Luthar, Suchman, & Altomare, 2007).
- Caveats: RPMG efficacy trials relied on masters/doctoral-level therapists; generalizability to community-level counselors remains to be tested (Luthar & Suchman, 2000; Luthar et al., 2007).
- Trauma-informed mindfulness interventions for parents with OUD showed improvements in parenting quality, especially for those with higher baseline adverse childhood experiences (Gannon, Mackenzie, Kaltenbach, & Abatemarco, 2017).
Strategy D: Effectiveness-Implementation Hybrid Designs (Type 1 and Type 2) to evaluate both outcomes and implementation processes in tandem (Curran et al., 2012; Wolfenden et al., 2016).
- Type 1: focus on effectiveness while collecting implementation data; Type 2: compare effectiveness and two or more implementation strategies to improve uptake.
- Application: test a parenting program in settings such as drug treatment centers, and collect data on sessions attended, fidelity, who delivered components (drug counselors vs. mental health professionals), and cross-site comparisons (e.g., child welfare vs. treatment facility).
- Rationale: reduces the number of separate studies and accelerates translation by evaluating practice-ready settings concurrently.

How the four strategies map onto practical steps

Adaptation (Strategy A): select efficacious programs (e.g., HANDS, NFP, PCIT, FCU) and tailor content to OUD contexts (opioid-specific treatment considerations, NAS/NOWS care, maternal emotion regulation, and co-occurring mental health needs). Ensure feasibility and pilot-test adaptations in relevant settings (e.g., residential treatment facilities).
Oversampling (Strategy B): in ongoing efficacy/effectiveness trials, deliberately recruit and retain parents with OUD; collect data to test moderation/mediation; compare outcomes between OUD and non-OUD groups; include measures of adolescent child outcomes and parental risk factors.
Testing in community (Strategy C): implement adapted or existing programs in community settings with real-world conditions; assess effectiveness and gather practitioner feedback; monitor treatment fidelity and potential delivery by non-specialist staff.
Hybrid designs (Strategy D): run trials that simultaneously evaluate clinical outcomes and implementation metrics (fidelity, acceptability, reach, cost, sustainability) to inform decisions about broader dissemination.

Practical examples and program adaptations mentioned

HANDS (Kentucky Health Access Nurturing Development Services) and Nurse-Family Partnership (NFP) have demonstrated benefits in maternal and child health outcomes, risk reduction for preterm birth, economic self-sufficiency, and prevention of abuse/neglect; these programs could be adapted to incorporate opioid-use specific content, MAT considerations during pregnancy, and NAS/NOW care (Williams et al., 2017; Olds, 2002).
PCIT (Parent Child Interaction Therapy): evidence for reducing negative parenting behaviors and preventing maltreatment; potential adaptation for parents with OUD, delivered by on-site therapists in residential drug treatment settings (Chaffin et al., 2004).
FCU (Family Check-Up) for toddlers to adolescents: improves parenting practices and family relationships; could address parental depression, which is common in this population (Dishion et al., 2014; Shaw et al., 2009).
MIO (Mothering Inside Out): pilot trials suggest potential benefits for mothers with OUD; ongoing trials to test efficacy across SUDs (Suchman et al., 2010; Suchman et al., 2011, 2017).
MST-BSF (Multisystemic Therapy for Building Stronger Families): adaptation for parents with SUDs; early results suggest improvements in child and parent outcomes; ongoing testing (Schaeffer et al., 2013; Zajac et al., 2015).
PUP (Parents Under Pressure): home-based program emphasizing emotion regulation to prevent relapse and improve parenting; evidence of reductions in child abuse risk and behavior problems (Dawe & Harnett, 2007).
RPMG (Relational Psychotherapy Mothers’ Group): 24-week group therapy including methadone counseling; reduced child abuse potential and parenting-related improvements; reductions in opioid use over time (Luthar & Suchman, 2000; Luthar et al., 2007).
Trauma-informed mindfulness interventions for parents with OUD show promise for improving parenting quality, particularly among those with higher adverse childhood experiences (Gannon et al., 2017).

Implementation challenges and considerations

Practical limits: many evidence-based programs (e.g., MST, NFP) operate with fixed resource constraints; integrating new mediators or moderators specific to OUD may be difficult without additional funding and staffing.
Oversampling feasibility: funding mechanisms often target a priori sample sizes; expanding recruitment to include more parents with OUD may require dedicated funding or policy incentives.
Multisubstance use and polysubstance use: many individuals with OUD misuse other substances (e.g., benzodiazepines, methamphetamine); evaluations should account for polysubstance use and its differential impact on intervention outcomes.
Sampling challenges: random sampling of all parents with OUD is difficult; representativeness should be discussed and reported (e.g., how well the sample matches the intended population).
Causality and design: ensuring causal inferences requires careful choice of comparison conditions, fidelity assessment, and appropriate outcome measures.
Training and workforce development: implementation requires training for staff delivering interventions in community settings; interdisciplinary collaboration is essential.
Data needs: robust mediation and moderation analyses (e.g., moderated mediation) require adequate sample sizes and careful measurement across stages.
Ethical considerations: stigma, confidentiality, and child welfare involvement require careful ethical oversight (Snoek & Horstkötter, 2018).

Potential impact and real-world relevance

Accelerating the pace of science can lead to more timely, scalable supports for children in families affected by OUD, potentially reducing adverse child outcomes and long-term costs to families and communities.
Integrating parenting supports within existing service systems (healthcare, substance use treatment, child welfare) can maximize reach and sustainability.
A transdiagnostic, ecologically grounded approach helps ensure interventions address both individual needs (emotion regulation, parenting knowledge) and contextual factors (social support, stigma, access to resources).

Conclusions

The rise in OUD and NAS/NOWS, along with the burden on families and child welfare systems, creates urgent demand for effective parenting interventions for parents with OUD.
The authors propose a concrete, ecologically informed roadmap to accelerate the translation of research into practice by (a) identifying malleable targets, (b) leveraging existing evidence-based parenting programs, (c) using oversampling and effectiveness-implementation hybrids, and (d) applying the NIH Stage Model alongside Bronfenbrenner’s ecological theory.
While there are logistical and ethical challenges, the outlined strategies offer a clear path to deliver timely, evidence-based supports to parents with OUD and their children.

Key equations and numeric references (LaTeX)

Time to translation from basic research to implementation (general benchmark): \text{Time to implementation} \approx 17\ \text{years}
Opioid use disorder among delivering women: \text{OUD prevalence}_{1999-2014} = 1.5 \to 6.5\ \text{per } 1000\text{ deliveries}
NAS/NOWS NAS rates in hospital births (1999 vs 2013): \text{NAS/NOWS}{1999}=1.5/1000, \qquad \text{NAS/NOWS}{2013}=6.0/1000
NAS/NOWS child welfare reports: 4.72\% \text{ (2004)} \rightarrow 9.19\% \text{ (2014)}
NIH Stage Model: six stages {0,1,2,3,4,5} with definitions as described above.
NAS/NOWS public health emergency declaration date: \text{October }2017 (DHHS).

References cited in context (selected examples)

Haight, Ko, Tong, Bohm, & Callaghan (2018) on OUD prevalence among women delivering.
Ko et al. (2016) on NAS/NOWS incidence.
Balas & Boren (2000); Onken et al. (2014) on implementation science and NIH Stage Model.
Peisch et al. (2018) on the current state of research on parenting with OUD.
Suchman et al. (2010, 2011, 2017) on MIO and related parenting interventions for SUD mothers.
Luthar & Suchman (2000, 2007) on RPMG; Dawe & Harnett (2007) on PUP.
Dishion et al. (2014); Shaw et al. (2009) on FCU and related family-based approaches.
Gannon et al. (2017) on mindfulness-based parenting interventions for mothers in treatment.
Rutherford, Berry, & Mayes (2018) on family-focused approaches to opioid addiction.
Powell (2013) on intervention outcome study design considerations and mediators/moderators.
Curran et al. (2012); Wolfenden et al. (2016) on effectiveness-implementation hybrid designs.
SUD-related studies across the references provide additional context for the discussed mechanisms and interventions.

Overview

The United States is grappling with a severe public health emergency characterized by a sharp rise in overdose deaths attributed to Opioid Use Disorder (OUD). This crisis extends its impact to families, leading to a significant increase in the number of children exposed to parents with OUD, thereby creating an urgent demand for specialized parenting interventions.

The conventional approach to scientific translation, which typically follows a linear path from basic science to program implementation, is notoriously slow. Historical data suggests that bringing findings from basic science to real-world impact can take approximately 17\text{ years}, a timeline that is unacceptably long given the current severity of the opioid crisis.

To address this urgency, the authors propose four distinct, yet interconnected, strategies designed to significantly accelerate the pace of scientific discovery and translation. The overarching aim of these strategies is to facilitate the more rapid improvement in parenting practices among parents with OUD.

The ultimate goal is to furnish a comprehensive roadmap for both researchers and practitioners. This roadmap is intended to guide them in the timely delivery of evidence-based interventions to families profoundly affected by OUD, ensuring that support reaches those in need more quickly and effectively.

Key epidemiological context and motivation

In October 2017, the U.S. Department of Health and Human Services officially declared a public health emergency. This declaration was a direct response to the escalating rates of overdose deaths linked to OUD, recognizing the profound and widespread impact of the crisis. A critical consequence of this emergency has been the dramatic increase in the number of children exposed to parental OUD, highlighting a pressing need for targeted support.

Prevalence Data
: The prevalence of OUD among women giving birth has shown an alarming trajectory. From just 1.5/1000\text{ deliveries} in 1999, this rate surged to 6.5/1000\text{ deliveries} by 2014, representing a greater than fourfold increase within a span of 15 years (Haight, Ko, Tong, Bohm, & Callaghan, 2018). This escalating trend underscores the growing number of infants potentially exposed to opioids prenatally.

Neonatal Outcomes
: Concomitantly, the incidence of Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS) has risen sharply, increasing by 300% over the period. The hospital birth rates for NAS/NOWS climbed from 1.5/1000\text{ hospital births} in 1999 to 6.0/1000\text{ hospital births} in 2013 (Ko et al., 2016). These conditions signify significant health challenges for newborns exposed to opioids.

Child Welfare Impact
: The burden on child welfare systems has also grown substantially. Reports related to NAS/NOWS accounted for 4.72% of all child welfare reports in 2004, a figure that nearly doubled to 9.19% by 2014 (Lynch, Sherman, Snyder, & Mattson, 2018). This demonstrates the intertwined nature of the opioid crisis, neonatal health, and child protection concerns.

Beyond Opioid Cessation
: Crucially, research indicates that achieving opioid cessation alone, while vital, does not automatically or reliably lead to improved parenting outcomes. Effective and sustained improvements in parenting practices require dedicated parent-training interventions and comprehensive environmental supports (Suchman, Decoste, McMahon, Rounsaville, & Mayes, 2011). This highlights that addressing OUD is a multifaceted challenge extending beyond simply managing substance use.

These compelling epidemiological data collectively emphasize the urgent need for accessible, scalable, and evidence-based parenting interventions specifically tailored for parents with OUD. Furthermore, there is an imperative for rapid translation of these interventions into practical, real-world settings to benefit affected families without undue delay.

Authors' Aims
: The authors outline two primary aims for their work: (1) to systematically identify malleable intervention targets and critical implementation considerations specifically relevant to parents navigating OUD; and (2) to propose concrete methods and strategic interventions designed to accelerate the pace of scientific advancement, thereby ensuring that evidence-based parenting supports reach families more rapidly and efficiently.

Theoretical foundations and frameworks

Bronfenbrenner’s Ecological Theory (1979, 1994): This foundational theory posits that human development is a complex process shaped by continuous interactions across multiple nested environmental systems. Applying this framework helps to identify various levels at which interventions can be targeted:

Microsystem
: This refers to an individual’s immediate environment, encompassing direct interpersonal interactions and relationships. For parents with OUD, this includes family members, partners, peers, and interactions within treatment settings. Interventions at this level might focus on improving family communication or partner support.

Mesosystem
: This layer involves the interactions and interconnections between different microsystems. An example in the context of OUD would be the relationship between parent–child interactions and a parent's engagement with their treatment facility, or how family dynamics influence their peer relationships.

Exosystem
: These are external settings that indirectly influence the individual's development, even though the individual may not directly participate in them. Examples include a parent's workplace policies (e.g., parental leave, drug testing), the support services available in their community (e.g., childcare, transportation), or the policies of child welfare agencies.

Macrosystem
: This represents the broadest level, encompassing cultural beliefs, societal values, laws, and overarching policies that shape the other systems. Stigma associated with OUD, cultural attitudes towards substance use and parenting, and national healthcare policies (e.g., funding for OUD treatment, insurance coverage) all operate at this level.

Chronosystem
: This dimension addresses the temporal dynamics, life transitions, and sociohistorical events that unfold over an individual's life course. For instance, the timing of an OUD diagnosis, changes in family structure over time, or the historical evolution of opioid treatment paradigms would be chronosystem influences.

NIH Stage Model for behavioral interventions (Onken et al., 2014): This model provides a structured, albeit flexible, framework for the systematic development and implementation of behavioral interventions. It outlines six stages:

Stage 0: Basic Research
: Focuses on understanding fundamental mechanisms, such as the psychological and neurobiological processes underlying OUD and parenting behaviors.

Stage 1: Intervention Generation and Refinement
: Involves developing new interventions or adapting existing ones, often through pilot testing and iterative adjustments based on feedback and preliminary data.

Stage 2: Efficacy Testing in Research Clinics
: Rigorous testing of an intervention under highly controlled conditions, typically in specialized research settings, to determine if it produces the desired effects.

Stage 3: Efficacy Testing in Community Clinics
: Evaluating the intervention's effectiveness when delivered in more realistic, community-based clinical settings, often with less control than Stage 2 but still focusing on internal validity.

Stage 4: Effectiveness Testing
: Assessing the intervention's impact in real-world practice settings with diverse populations, focusing on external validity and generalizability under typical service delivery conditions.

Stage 5: Implementation and Dissemination
: Concentrates on strategies to facilitate the widespread adoption, integration, and sustainment of the effective intervention into routine practice.

Note
: It's important to recognize that these stages are not strictly linear; researchers may move back and forth between stages, and not all stages must be fully completed for every intervention. The model primarily serves as a planning and communication tool to guide the research process.

Transdiagnostic Approach: The authors advocate for a transdiagnostic strategy. This involves leveraging interventions that have already demonstrated efficacy in other populations or for different conditions. The core idea is to identify and target shared underlying mechanisms (e.g., emotion dysregulation, impaired executive function) that cut across various disorders or populations, rather than developing entirely new OUD-specific interventions from scratch. This approach aims to accelerate scientific progress by adapting proven methods.

Integrated Framework: The paper proposes an innovative integration of the NIH Stage Model with Bronfenbrenner’s Ecological Theory. This combined framework is intended to systematically identify optimal intervention targets across different ecological levels and to address crucial implementation considerations for parents with OUD. The ultimate goal is to facilitate more rapid adoption of these interventions in diverse, real-world healthcare and community settings.

Goals of the review and roadmap

Goal 1: Review Extant Literature
: The initial objective is to thoroughly review existing scientific literature. This review aims to systematically identify malleable intervention targets—those aspects of individual, relational, or environmental functioning that can be modified through intervention—and implementation considerations that are particularly pertinent to parents who are affected by OUD.

Goal 2: Propose Concrete Methods and Interventions
: Building upon the literature review, the second goal is to propose specific, actionable methods and intervention strategies. These are designed to accelerate the pace of scientific translation by effectively leveraging the identified targets and implementation factors. This acceleration is critical for enabling the rapid and widespread dissemination of effective parenting supports to families in urgent need.

Deliver a Roadmap
: Ultimately, the work aims to deliver a practical and adaptable roadmap. This guide is intended for researchers and practitioners, providing clear guidance on how to adapt, rigorously test, and effectively implement evidence-based parenting interventions specifically tailored for parents with OUD, ensuring their relevance and impact.

Clarify Definitions
:

Parents
: For the purpose of this framework, “parents” are defined as individuals who are actively involved in parenting their child(ren), whether they reside in-home or in residential treatment settings. This broad definition ensures applicability across various living situations common among parents with OUD.

Parents with OUD
: This term refers to individuals who exhibit opioid misuse along the spectrum of disordered use. This includes, but is not limited to, those with a formal OUD diagnosis, and encompasses behaviors such as developing tolerance or withdrawal symptoms, or experiencing impaired control over opioid use. This definition captures a wider range of individuals who could benefit from interventions.

Contextual Note
: The article explicitly states that its framework and proposed strategies build upon and are informed by related research and interventions developed for other substance use disorders (SUDs) and comorbid conditions. These comorbid conditions often include trauma, various mental health disorders (e.g., depression, anxiety), and other co-occurring substance misuse issues. This approach leverages existing knowledge and avoids replicating efforts where common mechanisms are at play.

Key targets and mechanisms identified through the ecological lens

Individual considerations for identifying intervention targets

Individuals with OUD often present with a complex array of psychological and behavioral challenges, making individual-level intervention targets crucial:

Personality Disorders
: There is a higher prevalence of personality disorders among individuals with OUD, particularly those in Cluster B (which includes antisocial and borderline personality disorders) (Barry et al., 2016; Hans, Bernstein, & Henson, 1999). These disorders can significantly impact parenting capacity and treatment engagement.

Co-occurring Mental Health and SUDs
: Individuals with OUD are more likely to experience co-occurring anxiety, depression, and other Substance Use Disorders (SUDs) (Grattan et al., 2012; Hans et al., 1999; Brooner et al., 1997; Kidorf et al., 2018). These comorbidities necessitate integrated treatment approaches that address the full spectrum of a parent’s mental health needs.

Emotion Regulation Difficulties
: Challenges in emotion regulation are frequently observed in individuals with OUD. This relationship can be bidirectional: poor emotion regulation may serve as a precursor or trigger for opioid use, and conversely, opioid use and withdrawal can further impair emotion regulation abilities (Wolff et al., 2016; Wilens et al., 2013; Wilson et al., 2017; Tang et al., 2015). Interventions targeting these difficulties are thus highly relevant.

Parenting Beliefs and Knowledge Gaps
: Parents with OUD frequently exhibit inappropriate child expectations (e.g., expecting developmental milestones too early), may experience reversed parent–child roles (where the child assumes caregiving responsibilities), endorse corporal punishment, show lower empathy, and lack basic parenting information (such as recognizing illness signs, understanding proper nutrition, or knowing about infant development) (Rizzo et al., 2014; Butz et al., 1998).

Maternal Styles
: Studies indicate that mothers affected by OUD may exhibit somewhat reduced sensitivity and warmth in their parenting interactions. Furthermore, both adolescents and infants show less optimal dyadic interactions when maternal distress is high or opioid use is unmanaged (Salo et al., 2009; Salo et al., 2010; Sarfi et al., 2011).

Gender Differences
:

Fathers with OUD
: These individuals are more likely to live apart from their children. When they are involved in their children's lives, they often demonstrate reduced positive parenting behaviors and lower satisfaction with their parenting role (McMahon, Winkel, & Rounsaville, 2005).

Women with OUD
: Women with OUD tend to initiate opioid use via prescription more frequently. They also disproportionately face various health problems, unemployment, and significant childcare responsibilities. Their motivation for seeking treatment is often driven by pregnancy or concerns regarding child custody (Bawor et al., 2015; McMahon et al., 2002).

Prenatal Exposure vs. Postnatal Parenting
: While Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS) are prominent concerns during pregnancy, subsequent child outcomes are more strongly correlated with the quality of postnatal parenting and the overall environmental context than with prenatal opioid exposure alone (Lowe et al., 2017; Kaltenbach et al., 2018; Logan et al., 2014). This emphasizes the importance of ongoing parenting support.

Adverse Childhood Experiences (ACEs) in Parents
: Parents with OUD frequently report higher rates of ACEs in their own histories. These experiences are strongly linked to current parenting challenges and can also moderate the effectiveness of parenting interventions, suggesting a need for trauma-informed care (Shaw et al., 2009; Gannon et al., 2017).

Implications for Intervention Design
: Based on these individual considerations, effective interventions must be designed to specifically target and improve emotion regulation skills, enhance parenting knowledge and appropriate expectations, provide robust support for caregiving responsibilities, and reduce parenting-related stress, all within the complex context of OUD.

Yes, this article helps answer two of your three questions quite thoroughly, and touches on aspects of the first one, though not with extensive detail on specific long-term outcomes for children.

Here's a breakdown:

What are the long-term developmental and psychological outcomes for children who experience early and/or frequent parental separation due to the opioid epidemic?
- The article highlights the increased number of children exposed to parental OUD and the rise in Neonatal Abstinence Syndrome (NAS)/Neonatal Opioid Withdrawal Syndrome (NOWS). It also notes the increase in child welfare reports related to NAS/NOWS, implying significant disruptions for these children.
- Crucially, it mentions that "later child outcomes are more strongly linked to parenting quality and environmental context than prenatal opioid exposure alone" and that "history of home instability and attachment difficulties can be transmitted across generations." While it underscores the importance of these factors, it does not explicitly detail specific long-term developmental and psychological outcomes (e.g., rates of specific cognitive, emotional, or behavioral disorders) for children experiencing parental separation due to the opioid epidemic. It focuses more on the need for interventions and the factors influencing outcomes rather than a comprehensive list of the outcomes themselves.
How do existing support programs for caregivers of these children impact the children's well-being and long-term stability?
- The article provides substantial information here, discussing several programs and their observed impacts. For example:
  - HANDS (Kentucky Health Access Nurturing Development Services) and Nurse-Family Partnership (NFP): "demonstrated benefits in maternal and child health outcomes, risk reduction for preterm birth, economic self-sufficiency, and prevention of abuse/neglect."
  - Multisystemic Therapy–Building Stronger Families (MST-BSF): pilot results suggest it "can reduce youth anxiety, decrease maternal drug use, reduce depressive symptoms, and lower new substantiated maltreatment cases compared with standard care."
  - Parents Under Pressure (PUP): reports "reductions in child abuse potential, rigid parenting attitudes, and child behavior problems at 3- and 6-month follow-ups."
  - Relational Psychotherapy Mothers’ Group (RPMG): associated with "reduced child abuse potential, greater involvement with children, and improved maternal psychosocial functioning."
- These examples directly address aspects of children's well-being (e.g., reduced anxiety, fewer behavior problems, less maltreatment) and stability by improving the caregiving environment.
What are the most effective, evidence-based interventions for addressing the unique needs of this population?
- The article thoroughly covers this, dedicating sections to "Accelerating the pace of science: four strategic approaches" and "Practical examples and program adaptations mentioned."
- It advocates for adapting existing efficacious interventions (e.g., HANDS, NFP, PCIT, FCU) for parents with OUD and explicitly lists programs like PUP, RPMG, MIO, and MST-BSF as relevant, evidence-based interventions.
- It discusses how these programs target issues like emotion regulation, parenting knowledge, and reducing parenting-related stress, which are identified as unique needs of parents with OUD.
- The document also discusses strategies like oversampling in trials and using effectiveness-implementation hybrid designs to further test and disseminate these interventions, indicating their evidence-based nature and the focus on identifying the most effective approaches.

In summary, while the article clearly outlines the critical need for interventions and details several programs and their positive impacts on children's well-being and parental outcomes, it provides less direct granular data on the specific long-term developmental and psychological outcomes arising from separation itself. It is, however, highly relevant for understanding what interventions exist and how they work to mitigate negative outcomes.

Yes, this article helps answer two of your three questions quite thoroughly, and touches on aspects of the first one, though not with extensive detail on specific long-term outcomes for children.

Here's a breakdown:

What are the long-term developmental and psychological outcomes for children who experience early and/or frequent parental separation due to the opioid epidemic?
- The article highlights the increased number of children exposed to parental OUD and the rise in Neonatal Abstinence Syndrome (NAS)/Neonatal Opioid Withdrawal Syndrome (NOWS). It also notes the increase in child welfare reports related to NAS/NOWS, implying significant disruptions for these children.
- Crucially, it mentions that "later child outcomes are more strongly linked to parenting quality and environmental context than prenatal opioid exposure alone" and that "history of home instability and attachment difficulties can be transmitted across generations." While it underscores the importance of these factors, it does not explicitly detail specific long-term developmental and psychological outcomes (e.g., rates of specific cognitive, emotional, or behavioral disorders) for children experiencing parental separation due to the opioid epidemic. It focuses more on the need for interventions and the factors influencing outcomes rather than a comprehensive list of the outcomes themselves.
How do existing support programs for caregivers of these children impact the children's well-being and long-term stability?
- The article provides substantial information here, discussing several programs and their observed impacts. For example:
  - HANDS (Kentucky Health Access Nurturing Development Services) and Nurse-Family Partnership (NFP): "demonstrated benefits in maternal and child health outcomes, risk reduction for preterm birth, economic self-sufficiency, and prevention of abuse/neglect."
  - Multisystemic Therapy–Building Stronger Families (MST-BSF): pilot results suggest it "can reduce youth anxiety, decrease maternal drug use, reduce depressive symptoms, and lower new substantiated maltreatment cases compared with standard care."
  - Parents Under Pressure (PUP): reports "reductions in child abuse potential, rigid parenting attitudes, and child behavior problems at 3- and 6-month follow-ups."
  - Relational Psychotherapy Mothers’ Group (RPMG): associated with "reduced child abuse potential, greater involvement with children, and improved maternal psychosocial functioning."
- These examples directly address aspects of children's well-being (e.g., reduced anxiety, fewer behavior problems, less maltreatment) and stability by improving the caregiving environment.
What are the most effective, evidence-based interventions for addressing the unique needs of this population?
- The article thoroughly covers this, dedicating sections to "Accelerating the pace of science: four strategic approaches" and "Practical examples and program adaptations mentioned."
- It advocates for adapting existing efficacious interventions (e.g., HANDS, NFP, PCIT, FCU) for parents with OUD and explicitly lists programs like PUP, RPMG, MIO, and MST-BSF as relevant, evidence-based interventions.
- It discusses how these programs target issues like emotion regulation, parenting knowledge, and reducing parenting-related stress, which are identified as unique needs of parents with OUD.
- The document also discusses strategies like oversampling in trials and using effectiveness-implementation hybrid designs to further test and disseminate these interventions, indicating their evidence-based nature and the focus on identifying the most effective approaches.

Yes, this article helps answer two of your three questions quite thoroughly, and touches on aspects of the first one, though not with extensive detail on specific long-term outcomes for children.

Here's a breakdown:

What are the long-term developmental and psychological outcomes for children who experience early and/or frequent parental separation due to the opioid epidemic?
- The article highlights the increased number of children exposed to parental OUD and the rise in Neonatal Abstinence Syndrome (NAS)/Neonatal Opioid Withdrawal Syndrome (NOWS). It also notes the increase in child welfare reports related to NAS/NOWS, implying significant disruptions for these children.
- Crucially, it mentions that "later child outcomes are more strongly linked to parenting quality and environmental context than prenatal opioid exposure alone" and that "history of home instability and attachment difficulties can be transmitted across generations." While it underscores the importance of these factors, it does not explicitly detail specific long-term developmental and psychological outcomes (e.g., rates of specific cognitive, emotional, or behavioral disorders) for children experiencing parental separation due to the opioid epidemic. It focuses more on the need for interventions and the factors influencing outcomes rather than a comprehensive list of the outcomes themselves.
How do existing support programs for caregivers of these children impact the children's well-being and long-term stability?
- The article provides substantial information here, discussing several programs and their observed impacts. For example:
  - HANDS (Kentucky Health Access Nurturing Development Services) and Nurse-Family Partnership (NFP): "demonstrated benefits in maternal and child health outcomes, risk reduction for preterm birth, economic self-sufficiency, and prevention of abuse/neglect."
  - Multisystemic Therapy–Building Stronger Families (MST-BSF): pilot results suggest it "can reduce youth anxiety, decrease maternal drug use, reduce depressive symptoms, and lower new substantiated maltreatment cases compared with standard care."
  - Parents Under Pressure (PUP): reports "reductions in child abuse potential, rigid parenting attitudes, and child behavior problems at 3- and 6-month follow-ups."
  - Relational Psychotherapy Mothers’ Group (RPMG): associated with "reduced child abuse potential, greater involvement with children, and improved maternal psychosocial functioning."
- These examples directly address aspects of children's well-being (e.g., reduced anxiety, fewer behavior problems, less maltreatment) and stability by improving the caregiving environment.
What are the most effective, evidence-based interventions for addressing the unique needs of this population?
- The article thoroughly covers this, dedicating sections to "Accelerating the pace of science: four strategic approaches" and "Practical examples and program adaptations mentioned."
- It advocates for adapting existing efficacious interventions (e.g., HANDS, NFP, PCIT, FCU) for parents with OUD and explicitly lists programs like PUP, RPMG, MIO, and MST-BSF as relevant, evidence-based interventions.
- It discusses how these programs target issues like emotion regulation, parenting knowledge, and reducing parenting-related stress, which are identified as unique needs of parents with OUD.
- The document also discusses strategies like oversampling in trials and using effectiveness-implementation hybrid designs to further test and disseminate these interventions, indicating their evidence-based nature and the focus on identifying the most effective approaches.

Based on the article:

None of the specifically named programs you listed (HANDS, NFP, PCIT, FCU, PUP, RPMG, MIO, MST-BSF) are explicitly described in the article as being inherently trauma-based in their core design. Their descriptions focus on improving maternal/child health, parenting behaviors, family relationships, emotion regulation, and reducing abuse potential.

However, the article does mention a category of interventions that are trauma-based within the same section on "Practical examples and program adaptations mentioned." Specifically, it states:

"Trauma-informed mindfulness interventions for parents with OUD show promise for improving parenting quality, particularly among those with higher adverse childhood experiences (Gannon et al., 2017)."

The article consistently highlights the importance of addressing trauma. For instance, it notes the high prevalence of Adverse Childhood Experiences (ACEs) in parents with OUD and the need for interventions to account for these experiences, and emphasizes the need for training in healthcare settings to discuss addiction and trauma.

Based on the article:

However, the article does mention a category of interventions that are trauma-based within the same section on "Practical examples and program adaptations mentioned." Specifically, it states:

"Trauma-informed mindfulness interventions for parents with OUD show promise for improving parenting quality, particularly among those with higher adverse childhood experiences (Gannon et al., 2017)."