Examining unique substance-related risk profiles for neglectful behaviors among parents with and without clinical depression

Highlights

• Parental clinical depression creates unique risk and protection profiles for child neglect.

• Substance misuse with no co-occurring depression is associated with higher neglect counts.

• Tangible supports are protective for parents experiencing clinical depression.

• Social companionship appears protective only when parental functioning is not impaired.

Abstract

Background

Parental substance use disorder (SUD) is one of the predominant parental risk factors observed for child neglect. Yet, individual risks do not exist in a vacuum.

Objective

This study explored the relative importance of parental substance use behaviors based on the presence of key risk (clinical depression) and protective (social support type) factors.

Participants and setting

The final analytic sample was composed of 3,545 parents of children aged 2–17 years from Wave 4 data collection of the National Survey of Child and Adolescent Well-Being (NSCAW I).

Methods

Weighted negative binomial regression models examined the interactive relationship between parent self-report of past year substance use patterns, clinical depression, and social support type for annual neglect frequencies.

Results

Among parents meeting criteria for clinical depression, only parental SUD was associated with higher annual neglect frequency (compared to harmful/risky use); the presence of tangible supports was associated with lower annual neglect frequency while the presence of social companionship was associated with higher annual neglect frequency. For parents not meeting criteria for clinical depression, the study observed an interactive effect where both harmful/risky use behaviors and meeting criteria for SUD significantly contribute to higher average neglect frequencies compared to no past year use, depending on social companionship level.

Conclusions

In order to mitigate neglect risk among substance-using parents, practitioners should look beyond abstinence to address parents’ underlying cognitive/affective functioning and social context.

Introduction

Child neglect is the most predominant form of child maltreatment identified in the United States, representing 74.9% of identified victims and contributing to 75.4% of child fatalities during 2017 (U.S. Department of Health & Human Services, 2019). Neglect behaviors are acts of omission by a caregiver, such as not providing basic needs, medical care, emotional care, or adequate supervision, that cause or contribute to imminent physical, cognitive, and/or emotional harm to a child (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008). Effective prevention and early intervention endeavors are necessary to mitigate short- and long-term consequences of child neglect and their associated lifetime economic costs from increased medical, mental health, and education/employment needs (Fang, Brown, Florence, & Mercy, 2012). To achieve this, policy makers and practitioners need to be informed of change mechanisms that are responsive to psychological and social approaches. Parents experiencing substance use disorder, which in turn contributes to impairments in cognitive and affective functioning, is one of the predominant risk factors observed for parental neglect (Dunn et al., 2002). Yet, individual risks do not exist in a vacuum. In fact, the presence or absence of clinical depression likely influences the relative importance of risks factors like parental substance use and protective factors for child neglect, such as the presence of social support, creating complex dynamics between risk and protective factors (Stevens & Hassett, 2007).

Specifically, Belsky (1984) models how parenting behaviors, such as neglect, are influenced by multiple factors specific to the parent (i.e., cognitions and affect, gender), child (i.e., negative emotionality, emotion regulation, genetics), and social environmental (i.e., social support, family structure) domains (Taraban & Shaw, 2018). Building on this model, this study focuses on understanding how specific aspects of parental functioning and social environmental characteristics interact to create unique conditions for neglectful behavior, controlling for other parent, child, and household characteristics. For example, cognitive-affective processes affect how individuals both think and feel. Further, parental experiences of depression and substance use are likely to alter their cognitive-affective processes and influence parental disengagement associated with child neglect when examining these factors both individually and simultaneously (Belsky, 1984, Taraban and Shaw, 2018). Based on this model, interactions within domains and across domains are possible and likely. This study builds upon the theoretical and empirical literature by exploring the relationship between neglect frequency and a three-way interaction between (a) parent characteristic of clinical depression, (b) parent characteristic of substance use, and (c) family social environment characteristics of social support type. First, we explore how the presence of a parent meeting criteria for clinical levels of depression may result in different risk and protection profiles, with a specific focus on substance use and social support type. Then, we explore how neglect may occur more frequently within specific social contexts for parents reporting co-occurring clinical depression and substance use or substance use only.

By definition, both clinical depression and substance use disorders (SUD) can alter one’s mood and distort one’s perceptions; both conditions have the potential to impair other motor, biological, and social functions (American Psychiatric Association, 2013). Along these lines, clinical depression and SUD are often viewed as interdependent and correlated risk factors for neglect (Swendsen & Merikangas, 2000), with co-occurrence of SUD and psychiatric conditions arising in about half of SUD cases (Flynn & Brown, 2008). That being said, heterogeneity exists across individuals in relation to if and how comorbidity arises between SUD and depression, and our understanding of these relationships concerning neglect risk is not clear. For example, some evidence suggests clinical depression (and its underlying emotion dysregulation) equally or better explains risk for substance-related neglect (Lee et al., 2012, Slack et al., 2011, Stith et al., 2009), which is plausible given the strong positive association between the occurrence of depression and SUD (Lai, Cleary, Sitharthan, & Hunt, 2015). From a cumulative risk perspective, some evidence suggests there may be an additive effect where clinical depression and SUD uniquely add functional impairment that increases the risk for neglect (Kepple, 2018).

Alternatively, in this paper, we explore if an interactive effect between parental clinical depression and substance use behaviors exists, where parental substance use behaviors have distinct risks for neglectful behaviors depending on the presence or absence of parental depression. If neglect occurs from a failure to act, then factors individually and in combination can inhibit parental response to their children. This may be due to emotional withdrawal and impairment in abilities to recognize cues for child help (De Paul & Guibert, 2008). Both meeting criteria for SUD and major depressive disorder (MDD) are associated with disruptions in parent–child attachment (Herring and Kaslow, 2002, Kepple and Freisthler, 2020). In addition, prior reviews have consistently found only the most severe substance use behaviors (defined by meeting diagnostic standards for SUD) are associated with increased risk for neglect behaviors (Dunn et al., 2002, Kepple, 2018). However, direct effects of substances associated with high risk use, such as heavy drinking or other drug misuse, are likely to impair parental functioning during periods of intoxication and withdrawal, even when their substance use does not meet standards for SUD (Kepple & Freisthler, 2020). In addition, experiences with clinical levels of depression are associated with similar impairments to attention, working memory, and executive functioning as observed with substance misuse; however, only mixed evidence is present for association between depression severity and neurocognitive functioning (McClintock, Husain, Greer, & Cullum, 2010). To reconcile these two views, it may be that only SUD results in substantial enough impairment to affect parental functioning that is already impaired by parents experiencing clinical levels of depression. In contrast, a broader range of substance use behaviors may create risks for parents who do not experience clinical depression and whose functioning would not be compromised without the misuse of a psychoactive substance.

Belsky’s model also emphasizes that parenting behaviors must be situated within context, with specific emphasis on sources of stress and support within a parent’s network (Belsky, 1984). Although prior studies have emphasized that the presence of social supports is likely to be protective for neglect, many studies conflate tangible supports with social companionship despite their theoretically distinct nature (Thompson, 2015). For example, tangible supports are likely to provide resources, such as money, material goods/resources, or assistance with caring for children or household chores (DePanfilis, 1996). In theory, tangible social support may directly alter parenting resources that place children at risk for neglect-related harm. There also may be indirect benefits of perceived available tangible resources that affect parental cognitive-affective processes through reduced stress (Cohen & Wills, 1985). However, the empirical evidence is mixed regarding whether tangible supports are likely to reduce the likelihood of parents neglecting their children (Slack et al., 2011, Thompson, 2015). That being said, in contexts where parental functioning may be impaired by and social isolation may be more predominant due to parental depression, sources of tangible resources may be even more critical to buffering children from experiences of neglect by meeting basic needs when a parent is unable (Taraban et al., 2017). In contrast, these sources of support may not be as critical in contexts were parental functioning is not specifically impaired.

In contrast to tangible resources, social companionship is defined by the time spent in leisure and participating in recreational activities with others (DePanfilis, 1996). Social companionship may not always be protective of neglect since it can come with pressure to conform for acceptance without the benefits of resources that may directly protect against child neglect. While social companionship could be protective, it can also create potentially risky conditions when social norms within one’s network reinforce behaviors that pull a parent’s attention away from the needs of their child (Thompson, 2015). For example, Coohey (2008) observed that more than 65% of CPS-involved mothers who had more than one type of supervision problem were involved in recreational activities when supervisory neglect occurred. Further, we may expect an interaction between social companionship and parental characteristics, such as clinical depression (Taraban & Shaw, 2018), which can further distract parents whose cognitive and affective functioning may be compromised in ways that contribute to poor decision-making (McClintock et al., 2010). Within the context of parental depression, the increased availability of people to engage in recreational activities also may serve as a form of escapism from stressors of daily life, such as meeting child needs, creating conditions where isolation from this specific type of social support may be protective of child neglect (Hastall, 2017).

Family and friends able to provide tangible supports may also provide informal interventions with a parent (e.g., provision of temporary child custody or care), protecting children from neglect in situations where parental functioning is impaired due to parental substance use behaviors, even when clinical depression is not present (Barnard, 2003, Taplin and Mattick, 2013). Within the context of substance use where clinical depression may not be present, mothers with current substance use concerns requiring treatment reported that beyond family members, their networks were primarily composed of individuals with whom the women had engaged in substance use or were current substance users (Tracy et al., 2012). In addition, prior work observed parents who report drinking more frequently with friends were more likely to report supervisory neglect behaviors (Freisthler, Price Wolf, & Johnson-Motoyama, 2015). Therefore, social companionship may not be protective in conditions where parents are more likely to socialize with other high-risk users. Substance use behaviors might be reinforced and contribute to normalized social rituals that increase the risk for child neglect, such as increased tolerance for the child to be in unsafe environments (Zinberg, 1984). As a result, being recreationally isolated through no identified sources of social companionship may be protective for parents meeting criteria for SUD in ways that are not observed among parents reporting other substance use behavior patterns (i.e., light to moderate drinking or high risk use).

Less is understood about how social supports may moderate the relationship between parental substance use and neglect behaviors for parents experiencing co-morbid clinical depression. If clinical depression equally or better explains risk for substance-related neglect when comorbid conditions of depression and substance misuse are present, then it logically would make sense that social support type, defined by either tangible resources or social companionship, would not further moderate relationships by type of substance use behaviors given parental impairments would be present across a range of substance use behaviors. However, if a cumulative risk results from the presence of comorbid MDD and SUD, then it may be that we observe higher frequencies of neglect among parents seeking escapism through recreationally-focused supports, who also are more likely to reinforce substance use behaviors.

Our aim is to understand the multi-determined nature of neglectful parenting within specific contexts. First, we examine how the relationship between neglect frequency and previously identified risk and protection factors are moderated by the presence or absence of parental clinical depression. For this paper, we highlight differences in estimated neglect frequencies for parental substance use behaviors, tangible support levels, and social companionship levels by parental clinical depression. We further explore how the relationship between substance use behaviors and neglect frequency are moderated by levels of tangible support or social companionship for parents diagnosed with and without clinical depression, given preliminary evidence that not all supports may be protective within the context of parental use of alcohol and other drugs. In other words, a simple social support story may not adequately explain neglect risk within this parenting context. Using Belsky’s process model of parenting (Belsky, 1984, Taraban and Shaw, 2018) to guide our study, we aim to gain a more nuanced understanding of the specific parenting characteristics and conditions to help us tailor prevention and intervention efforts to better address client needs.

To achieve these study aims, three research questions were addressed. First, are the risk and protective profiles for past year neglect frequency moderated by whether or not a parent meets the criteria for clinical depression within the past year? We hypothesize that the relationship between neglect frequency and substance use behaviors is moderated by the presence of parental clinical depression, such that only SUD results in severe enough impairment to contribute to parental impairments who are already experiencing clinical levels of depression. In contrast, a broader range of substance use behaviors may be associated with neglect frequency for parents who do not experience clinical depression. In addition, we hypothesize that parent perceptions of available tangible supports are likely to be associated with a reduced neglect frequency for parents with a need to buffer the effects of clinical depression; however, tangible supports may not be associated with neglect frequency for parents who do not experience clinical depression. Finally, within each parental depression subgroup, is the relationship between parental substance use behavior patterns and neglect frequency moderated by tangible support and social companionship level? We hypothesize no further moderating effects by tangible supports for parents reporting clinical depression, due to parental functional impairments likely arising from parents experiencing clinical level of depressive symptoms regardless of substance use behaviors. In contrast, we are likely to observe lower neglect frequency among parents reporting SUD only and higher levels of tangible supports compared to parents reporting SUD only and lower levels of tangible supports. For social companionship, we hypothesize that high levels of social companionship may result in a higher frequency of neglect compared to lower levels of social companionship, particularly for parents experiencing SUD and further exacerbated by the presence of clinical depression.