Substance abuse among women is a serious problem for parenting and represents considerable human and financial burden to society. Estimates suggest that 50-80% of child welfare cases involve a parent who abuses alcohol or other drugs and mothers make up the majority of substance-abusing parents in the child welfare system [1, 2]. In the United States, up to 70% of women in substance abuse treatment have children . Rates of substance abuse in women have been increasing  and substance abuse in women also is associated with a unique constellation of risk factors and needs, including greater vulnerability to adverse physiological consequences than men, greater prevalence of mental health problems, histories of physical or sexual abuse, serious medical problems, poor nutrition, relationship problems including domestic violence, and deficits in social support [4, 5]. The unique risk factors and presenting needs of women have resulted in the development of women-specific comprehensive treatment models . However, in addition to having gender-specific needs, women with substance abuse issues also have unique needs as mothers.
Research has shown that women who abuse substances may have difficulties providing stable, nurturing environments for their children compounded by challenging life circumstances, including severe economic and social problems, such as lack of affordable housing and homelessness . Their children are at greater risk for impaired physical growth, development, and health, poor cognitive functioning and school performance, emotional and behavioural problems, psychiatric disorders, and substance use themselves [7, 8]. Despite their best intentions, women with substance abuse issues are at risk for a wide range of parenting deficits . Parenting can be operationalized as skills (e.g., interacting sensitively, facilitating sleeping and eating routines), attitudes (e.g., empathy, positive approaches to behaviour guidance), knowledge (understanding child development), or capacity (e.g., maternal custody, lack of need for child protection services involvement). Parenting among mothers with substance abuse issues may be impaired by the primacy of satisfying their addiction over the welfare of themselves and their children, the emotional lability that is associated with intoxication or withdrawal, the impairment from chronic drug use, and their consequent unavailability to their children . Further, women with substance abuse issues often have high levels of comorbid psychopathology and personality problems [10–13], which can impair emotional responsiveness and cognitive abilities and negatively impact parenting .
As maternal substance abuse is a growing problem, there is an urgent need to identify effective interventions. Treatment for mothers with substance abuse issues and their children may represent an important opportunity for breaking the intergenerational cycle of addiction and dysfunction and improving parenting. However, women with substance abuse issues report difficulties using conventional systems of care (for reasons including fear of losing custody of children, guilt, stigma, and lack of transportation), and request comprehensive services provided in a caring, 'one-stop' setting . Given the barriers, risks, and outcome implications, researchers, clinicians, and policy makers recommend that substance abuse treatment programs address women's needs as well as their children's needs through comprehensive, integrated services in centralized settings for both women and children . This recognition has resulted in the development of numerous integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services), both residential and outpatient. Integrated residential programs or "therapeutic communities" offer long-term (15-18 months) treatment services to women and their children. Both types of programs typically are comprehensive and include group and individual addiction treatment, maternal mental health services, trauma treatment, parenting education and counseling, life skills training, prenatal education, medical and nutrition services, education and employment assistance, child care, children's services, and aftercare.
Parenting is an important outcome of intervention because it impacts child outcomes . Studies of parenting interventions with other at-risk populations have shown that improving parenting can improve outcomes for children [16–18]. For example, early prevention programs designed to enhance protective factors (i.e., positive parent-child interaction and parenting behaviour) and reduce risk factors (e.g., hostile, negative, or overreactive parenting) prevent later disruptive behaviour disorders in children and adolescents at risk . Thus, the risks to children of women with substance abuse issues could be minimized with intervention. If intervention for mothers with substance abuse issues is successful in improving parenting outcomes, it may reduce costs (in terms of foster care placement, emergency room visits, medical and psychiatric admissions, child treatment, crime, etc.) and enhance healthcare and social service delivery.
To date, no systematic reviews of quantitative studies of parenting outcomes of integrated programs have been conducted. Gender specific (i.e., women only) substance use treatment was examined in one systematic review and one meta-analysis. In their systematic review of 38 studies, Ashley, Marsden, and Brady  found that programs with prenatal care or child care were associated with improved outcomes (substance use, mental health, birth outcomes, employment, and health). Similarly, in their meta-analysis, Orwin, Francisco, and Bernichon  concluded that enhancing women-only addiction treatment programs with prenatal care or therapeutic child care added value above and beyond the effects of standard women-only programs. Neither of these reviews specifically focused on integrated programs or examined parenting outcomes, despite the potential implications for prevention, harm reduction, improving public health, and reducing the burden to society.
We examined the effectiveness of integrated programs on parenting outcomes in a systematic review of relevant studies. The specific research questions guiding this systematic review were: 1) Are integrated programs more effective than addiction treatment-as-usual in improving parenting outcomes?; and 2) Are some integrated program characteristics associated with better parenting outcomes than others?