Project Summary/Abstract Mothers with substance use disorders (SUDs) face unique challenges with respect to the intersection of parenting and recovery. For this reason, they rarely benefit from evidence-based parenting interventions that have been brought to scale with the general public or child behavioral problems in mind. A different approach is needed. Mothering from the Inside Out (MIO) is the first attachment-based parenting intervention for mothers with SUDs that targets parental reflective functioning (RF). Parental RF is the capacity to (a) identify and regulate emotions that are activated during stressful parenting situations and (b) accurately recognize and understand young children’s need for stability, security, and sensitivity in the mother-child relationship. MIO has been shown to have bigenerational benefit by improving parental RF, maternal caregiving, and children’s attachment security while also reducing maternal psychiatric distress and relapse to substance use when delivered by researchers in randomized clinical trials with mothers enrolled in outpatient substance use treatment. However, in the third community-based efficacy trial when delivered by SUD treatment counselors, MIO was not associated with the same magnitude of improvement in RF or caregiving behaviors, raising important questions about the science-to-service gap. There remains a critical need to understand the implementation factors that may be related to enhanced treatment outcomes for MIO when delivered under ‘real-world’ conditions. Therefore, we propose to test MIO’s effectiveness when delivered in four substance use treatment programs where responsibility for MIO training and delivery will be assumed by community-based treatment providers. We also propose to conduct an implementation evaluation to examine key implementation constructs when integrated in four outpatient SUD treatment clinics. In this Type I hybrid effectiveness- implementation study, we will (a) conduct a randomized effectiveness trial where 200 mothers will be randomized to receive MIO plus standard outpatient SUD services versus standard outpatient SUD services alone; (b) replicate testing of the MIO mechanism of change with a larger cohort of counselors and clients; and (c) assess the impact of key implementation constructs on real-world delivery of MIO. Data collected in the effectiveness trial and the implementation evaluation will allow us to test causal effects and mechanisms of change within MIO under natural conditions while also gaining greater understanding of the implementation process to guide future large-scale implementation and dissemination projects. MIO has demonstrated the potential to interrupt a pernicious cycle involving the disruption of early attachment relationships that represents risk for the health of both mother and child. This Type I hybrid effectiveness-implementation study will accelerate our progress in bringing MIO to scale while ensuring continued methodological rigor aimed at optimizing treatment outcomes under real-world conditions.

PROJECT NARRATIVE Mothers with substance use disorders face unprecedented stress in their roles as parents working to care for their children while maintaining healthy recovery. Mothering from the Inside Out (MIO) is the first attachment- based parenting intervention designed specifically for mothers in recovery from substance use disorders that has been shown to have bigenerational benefit in multiple randomized controlled trials. This project will: (a) test the effectiveness of MIO among women in outpatient addiction treatment under ‘real-world’ conditions, (b) further elucidate the MIO mechanism of change associated with improvements in caregiver behavior and maternal mental health outcomes, and (c) assess key implementation constructs to support optimal uptake and treatment in future dissemination studies; closing an important science-to-service gap for an underserved population in an effort to support maternal and child health simultaneously.