Children at Risk Understanding Substance Abuse and Facilitating Recovery

Transcription

1 Children at Risk Understanding Substance Abuse and Facilitating Recovery A Guide for Child Wlf Welfare Workers Darran M. Duchene, MSW, MPSA Director, Treatment Services Substance Abuse Program Office

2 Seminar Training i Goals! Identify the impact parental substance abuse has on children. Recognize when substance abuse is a factor in child welfare. Understand signs and effects of addiction. Help understand and facilitate treatment and recovery.

3 Seminar Training i Goals! Identify strategies to enhance motivation. Enhance collaboration with substance abuse providers. Improve outcomes for children with parents with substance use disorders. Identify strategies that support women in treatment and recovery.

4 Children at Risk..! Nationally, 50% of substantiated cases of child abuse and neglect involve parental substance abuse. In 2002, 2,454 children were found to be victims of abuse and neglect everyday. Parental addiction is a significant predicator of childhood abuse/neglect.

5 Effects of Parental Substance Abuse on Children Increase risk for developing an addiction. Prenatal substance exposure. Higher incidence of depression and anxiety. Lack of consistency and structure. Economic instability. Parental incarceration. Higher risk for entering foster care. Child Welfare and Substance Abuse Erica Tarasovitch, MSW

6 Effects of Parental Substance Abuse on Child Development Physical health consequences. Lack of secure attachment. Language delays and communication disorders. Psychopathology. Bh Behavioral problems. Poor social relations and skills. Deficits in motor skills. Cognition and learning disabilities. Child Welfare and Substance Abuse Erica Tarasovitch, MSW

7 A Child s Point of View

8 Effects of Parental Substance Abuse Parenting Unclear expectation for behavior. Poor monitoring of behavior. Inconsistent minimal rewards for behavior. Inconsistent discipline. Over or under involvement with children. Lack of bonding or closeness with family members. Family conflict or lack of involvement in family activities. Linda Mann, MSW, LCSW, CAP

9 Domestic Violence and Parental Substance Abuse Men who commit acts of domestic violence frequently have substance abuse problems. Children often witness spousal abuse. Female victims of domestic violence have increase risk of prescription drug and alcohol abuse. Child Welfare and Substance Abuse Erica Tarasovitch, MSW

10 Legal Standards for When Substance Use is Child Neglect or Abuse Evidence that parental addiction is adversely harming the child. The detection and presence of alcohol or a controlled substance at birth. Giving a child alcohol or other drugs including prescription drugs that cause substantial harm. Child Welfare and Substance Abuse Erica Tarasovitch, MSW

11 Child Welfare Workers Must Determine! Is alcohol and drug use a factor in the reported abuse and neglect? If substance use is a factor, an assessment needs to be completed. An assessment will determine where the parent is on the use/abuse/dependence continuum.

12 What is Addiction? Addiction is a treatable disease that is chronic and relapsing. Addiction is progressive and never cured. Addiction is similar to chronic diseases such as diabetes, asthma, & high-blood pressure. Relapse is frequently a part of addiction. Addiction often co-occurs with other medical and mental health problems. Linda Mann, MSW, LCSW, CAP

13 Addiction is a Family Disease Needing Treatment Every member of the family is adversely impacted by addiction. Addiction causes extreme fear and anxiety in the family like a constant fire alarm. To survive, family members often assume lifelong enabling and/or self-defeating behavior patterns. Linda Mann, MSW, LCSW, CAP

14 Signs of Addiction Physical changes in the body such as tolerance or withdrawal. Severe alcohol withdrawal includes the shakes, agitation and hallucinations. Detox is often necessary to help people medically manage withdrawal symptoms.

15 Psychological l Addiction People Need Alcohol or Drugs To: Relax Feel good Reward themselves Positive alcohol expectancies Avoid feeling worse Function as a parent To reduce guilt

16 CW Staff Must Consider How does drinking affect the parent s ability to make sound judgments regarding the welfare and safety of the child? Does the parent s behaviors after drinking place the child in greater risk. Education about level of use is warranted.

17 Understanding Use/Abuse/Dependence. Substance use occurs along a continuum: Experimental.. p Social.. Moderate.. High-Risk.. Abuse.. Dependence =Addiction =Alcoholism

18 Diagnosing Substance Abuse At least ONE of these factors in the past 12 months: Recurrent use resulting in a failure to fulfill obligations at work, school, or home. Recurrent use in situations which are physically dangerous like operating equipment or driving a car.

19 Diagnosing Substance Abuse At least ONE of these factors in the past 12 months: Recurrent substance-related legal problems. Continued use despite social and interpersonal problems.

20 Diagnosing Substance Dependence Substance Dependence: 3 or more factors in the past 12 months Tolerance: needing more of the substance to get high. Withdrawal: physical and psychological symptoms.

21 Diagnosing Substance Dependence Substance Dependence: 3 or more factors in the past 12 months More of the substance is taken over a longer period than was intended. Unsuccessful efforts at cutting down or controlling substance use.

22 Diagnosing Substance Dependence Substance Dependence: 3 or more factors in the past 12 months Great deal of time is spent obtaining the substance or recovering from its effects. Social, occupational, or recreational activities are given up.

23 Diagnosing Substance Dependence Substance Dependence: 3 or more in the past 12 months Use is continued despite awareness about the presence of physical or mental health problems. Dependence is also known as Addiction.

24 Parental Addiction Increases Risks for Children Use during pregnancy can harm the fetus. Misuse/abuse of prescription p pain medications. Driving with children in the car while under the influence. Children may be left in unsafe care while parent is partying or buying drugs. Other caregivers including grandparents can poise a serious risk to children.

25 Parental Addiction Increases Risks for Children Parent may neglect the children s needs for regular meals, clothing, and cleanliness. Even when the parent is in the home, the parent s use may leave children unsupervised. Behavior toward children may be inconsistent, such as a pattern of violence then remorse.

26 Women and Substance Abuse Less alcohol for women to get intoxicated. Women progress to addiction in less time than men. Many yhave experienced physical or sexual abuse in childhood.

27 Women and Substance Abuse May come from family histories of dysfunction and addiction. Experiences of domestic violence and/or sexual victimization as adults. Co-occurring eating disorders, BPD, anxiety/depression and/or trauma/ptsd.

28 Parental Substance Abuse: Co-Occurring Disorders Co-occurring disorders refers to co-occurring substance use and mental health disorders. One or more substance use and one or more mental health disorder. Child welfare workers need to be alert to both substance use and mental health disorders.

29 Is Substance Abuse a Factor in Abuse or Neglect? In-home examination for alcohol or drug involvement. Screening the parent or caretaker for alcohol and drug use or abuse is the first step in identifying an alcohol or drug problem. Important to know how to be direct without being confrontational.

30 In-Home Examination for Alcohol and Drug Involvement: A report of substance use is included in the child protective services report. Paraphernalia is found in the home. Smell of alcohol, marijuana, or drugs. Child C reports parental use.

31 In-Home Examination for Alcohol and Drug Involvement: A parent appears to be under the influence like slurred speech. A parent shows signs of addiction like needle tracks or burns on inside of lips. A parent admits to substance use.

32 In-Home Examination for Alcohol and Drug Involvement: A parent shows or reports experiencing physical effects of addiction. Shows or reports signs of tolerance or withdrawal. Observe persons who frequent the home.

33 Best Practices: Screening the Parent Child welfare workers should ask parents and adult caretakers about their substance use in a nonjudgmental manner. Motivational screening helps determine if a more complete assessment is necessary? Elicit the parent s view of their substance use to help reduce denial and resistance.

34 Who Should be Screened? All adults in the household. Other adults connected to the case. Extended family members. Older children in the home.

35 Screening Tools: UNCOPE U - Have you continued to USE alcohol or drugs longer than you intended? Or, have you spent more time drinking or using than you intended? N - Have you ever NEGLECTED some of your usual responsibilities because of alcohol or drug use?

36 Screening Tool: UNCOPE C - Have you ever wanted to stop using alcohol or drugs but couldn t? (CUT down) O - Has your family, a friend, or anyone else ever told you they OBJECTED to your alcohol lor drug use?

37 Screening Tool: UNCOPE P - Have you ever found yourself PREOCCUPIED with wanting to use alcohol or drugs? Or, have you frequently found yourself thinking about a drink or getting high? E - Have you ever er used alcohol or drugs to relieve EMOTIONAL discomfort, such as sadness, anger, or boredom?

38 What to Do When Alcohol or Drug Abuse May Be Present Positive screening indicates the parent should receive an alcohol and other drug assessment. Substance use should be coordinated in the child welfare and treatment case plans. The child should be assessed and treatment should be addressed in the case plan.

39 Methamphetamine Use and Impact on Children Has resulted in a dramatic escalation in the severity of child abuse crimes. Exposed to toxic chemicals, waste and filth associated with methamphetamine production. Lack of parental supervision contributes to children ingesting contaminated food and chemicals.

40 Talking With Children About Parental Substance Use Your parent is not a bad person; they may have a problem, illness or disease. Parents may do mean or stupid things when they drink too much or use drugs. You are not the reason your parent drinks or uses drugs. You did not cause their alcohol or other drug problem and you cannot stop it.

41 Talking With Children About Parental Substance Use Many kids have parents that have problems with addiction. It s normal for you to have strong feelings. You are not alone. There is hope and help. You can talk about the problem. Find someone you can trust. Many ycommunities have Alateen meetings.

42 Cultural l and Ethnic Sensitivity It s important to understand and display cultural, racial and ethnic sensitivity. Addiction is an equal opportunity disease. Work with the cultural not against it.

43 Best Practices in Treatment t Employ a recovery perspective. Adopt p a multi-problem viewpoint. Develop a phased approach to treatment. Address real-life problems early in treatment. Use support systems to maintain and extend treatment. Use a motivational approach. Reduce barriers to treatment. SAMSHA s Co-Occurring Center for Excellence

44 Detoxification ti Services A process to assist clients to withdraw from the physiological and psychological effects of substance abuse. Untreated withdrawal may be medically dangerous or even fatal. Detox can motivate people to enter and continue with treatment.

45 When To Refer for Detox Current use/abuse of opiates. Current consistent use/abuse of alcohol. Ask parent, What happens and how do you feel when you don t use for a few days.

46 Clinical i l Treatment t Services Outreach and engagement. Screening. Detoxification. Crisis intervention. Substance abuse counseling and education. Trauma specific activities. Medical care. Mental health services. Drug monitoring. Continuing care.

47 Clinical i l Support Services Primary health care. Life skills. Parenting and child development education. Family programs. Employment readiness services. Linkages with legal system and child welfare system. Housing support. Advocacy. Recovery community support services.

48 Community Treatment t Support Recovery management. Family strengthening. Transportation. Child care. Temporary Assistance for Needy Families. Employer support services. Vocational and academic education services. Faith based organization support.

49 Stages of Recovery? Stabilization: detox and enters treatment. Early recovery: insight into understanding the events that led up to entering treatment. Middle recovery: commits to long term treatment with a recovery plan. Late Recovery: addresses major life issues sober and may begin spiritual journey. Maintenance: Accepts and commits to long term recovery.

50 Treatment and Recovery Issues Specific to Women May have low self-esteem, low selfconfidence and may feel powerless. Women appear to become addicted more rapidly than men. Use of support groups may have greater benefits for women.

51 Treatment and Recovery Issues Specific to Women Group counseling reduces rates of relapse for women. More women experience depression in treatment than men. Risks for co-occurring disorders, trauma, victimization, eating disorders, sexual assault. Continuing relationship with treatment provider found helpful l for women.

52 Self-Help l or 12 Step Groups Twelve Step Facilitation Therapy supporting a person s participation in: Alcoholics Anonymous (AA) Narcotics Anonymous (NA) Alanon Alateen

53 How Can You Motivate Parents To Enter Treatment? The majority of people who need treatment don t want it. Educate parents and substance abuse providers about time requirements for compliance with the Adoption and Safe Families Act. Website: Adoption.com

54 What is Motivational Interviewing? MI is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. MI is client centered therapy with a twist. It s more like dancing than wrestling. We listen more than we talk. We ask permission to give a suggestion or ask a question. Miller & Rollnick, 2002)

55 Enhancing Motivation to Change Client s don t need more confrontation They need more validation, compassion and empathy Sometimes they just need to be heard People change when others stop trying to change them ( Jacobson & Christensen, 1996)

56 Brief Interventions FRAMES Feedback: provide nonjudgmental feedback. Responsibility: p y encourage client responsibility. Advise: offer advice. Menu: provide a menu of options. Empathic: p be empathic. Self-Efficacy: support self-efficacy. Tip 34 Brief Interventions and Brief Therapies for Substance Abuse

57 Four Guiding Principles of Motivational Interviewing Express empathy through reflective listening. Develop discrepancy between clients goals and values and their current behaviors Avoid arguments and roll with resistance. Support S self-efficacy and optimism.

58 Brief Interventions For High- Risk Drinking Parents Every contact is opportunity for an intervention. Have open direct conversation about substance use and child safety. Nonjudgmental open ended questions enhance the relationship and build trust.

59 Listen Reflectively l Reflection is the single most important MI skill. Listen carefully and think reflectively. Reflect back in a statement what you think y you heard the client say. Do you mean?

60 Readiness to Change Does the parent recognize that they have a problem? Do they have mixed feelings about change? Are they ready to change? Do they blame others for their problems? Do they view their behavior as normal? Do they view change as too difficult?

61 Key Readiness to Change Factors Perception of need to change. Belief that change is possible. Confidence that one can change. Stated intention to change.

62 Motivational Strategies for Parent s Stage of Change Pre-contemplation: I don t have a problem and don t need to change. Motivational Strategy: Increase the parent s awareness of the risks and problems with their current behaviors.

63 Motivational Strategies for Parent s Stage of Change Contemplation: I might have a problem but I ambivalent about change. Motivational Strategies: Evoke reasons for change. Explore the pros and cons of change and not changing. Tip the balance in the direction of change.

64 Motivational Strategies for Parent s Stage of Change Preparation: Parent is deciding and preparing to change. Motivational Strategies: Review a menu of change options. Develop A Plan for Change Assess the strength of client change, talk. Discuss steps involved in change. Review what has worked with other clients.

65 Motivational Strategies for Parent s Stage of Change Action: I am starting to change. Motivational Strategies: Help pparent implement strategy and steps. Listen and affirm client progress and success. Continue to build self-efficacy efficacy. Reaffirm clients decision to change.

66 Motivational Strategies for Parent s Stage of Change Maintenance: I am actively working and maintaining long term change. Motivational Strategies: Identify triggers Provide relapse prevention. A slip is a learning experience. Reinforce what s working.

67 Motivational Strategies for Parent s Stage of Change Lapse or Relapse: Parent slips from change strategy or relapses and returns to previous problem behavior patterns. Motivational Strategies: Help parent re-engage in contemplation, preparation, and action stages.

68 Provide Recovery Support and Relapse Prevention Help parent identify stressors, triggers, high-risk situations or warning signs. Complete the relapse warning signs and recovery support plan worksheets. Increase positive healthy activities and lifestyles. Increase involvement in self-help groups.

69 Defining a Lapse and Relapse Lapse is a period of substance use. Relapse is a return to the problem behaviors associated with substance use. Educate clients about coping with cravings, slips, lapses, relapses and urge surfing.

70 Recovery Support Plan To Prevent Relapse Parents can plan for safety of their children. Seek healthy ways to avoid and cope with triggers that reduce risk and harm. Carry an emergency card with your plan of action. Develop plans for parents to minimize the impact on their children.

71 Supporting Recovery for Women Women relapse less than men. More likely to engage in group counseling than men. Negative g emotions and interpersonal problems are triggers for relapse with women.

72 Supporting Recovery for Women Regular and frequent visitation with children and planning for their return can enhance motivation for abstinence. Frequent parent-child visits sometimes conflict with early treatment restrictions about visitation. CW and SA providers should develop a collaborative case plan.

73 Barriers to Treatment for Women Transportation. Safety y of children and childcare. Health. Strained interpersonal relationships Financial stressors. Prior trauma. Domestic violence. Partners who still use.

74 Cross-System Communication and Collaboration Collaboration is a mutually beneficial and well-defined relationship entered into by two or more entities to achieve common goals. Collaboration better meets the needs of children and families.

75 Research on Effective Collaboration Mutual respect, understanding, and trust. Open p and frequent communication. Partners see collaboration in their interest. A mutual sense of ownership. Formal and informal communication. Concrete, attainable goals and objectives.

76 Research on Effective Collaboration Learn about your partner. Establish a working relationship. Understand and value each other. Acknowledge g boundaries. Seek supervision. Identify areas of collaboration.

77 Why Treatment Providers Are Needed? To conduct a substance abuse assessment or evaluation. Identify the level and type of treatment needed. Participate in case management and monitoring. Crisis intervention and trauma related services.

78 Why Substance Abuse Providers Need to Partner with Child Welfare Worker Parenting skills and child safety in the family are areas in which the child welfare worker has expertise. Remind parents and treatment providers of Adoption and Safe Families Act.

79 Issues and Services Included in Collaboration Confidentiality consent forms follow federal guidelines. Forms address the purpose of disclosure, the information to be disclosed and the time limits on disclosure. Keeping information confidential is good legal and ethical practice.

80 Issues and Services Included in Collaboration Child welfare workers can help educate substance abuse providers about the child welfare system. Help understand the Adoption and Safe Families Act. Explain in-home cases, court cases, or if the child has been removed.

81 Issues and Services Included in Collaboration Child Welfare Workers Educate substance abuse counselors: Understand the priority for immediate child safety. The need to reduce future risk. That safety and risk must be assessed while the case is active.

82 Child Welfare Workers Explain the development of court reports. Types of progress information needed for child welfare case plans. Treatment and recovery yprogress information.

83 Child Welfare Workers Share permanency plans. What is the permanency yplan for the child? What is the goal for reunification? What is the optimal parent/child visitation schedule? Is there a concurrent plan?

84 Areas to Include in Collaboration Assess what the children and family needs. Provide contact if on a waiting list. Case planning. Motivational strategies. Identify supports and other partners. Coordinate case management. Monitor treatment and recovery. Follow-up. Decide how to address slips and relapses. Ongoing assessment of child safety and risk of harm.

85 Resources The Administration for Children and Families. The National Institute on Alcohol Abuse and Alcoholism. li The National Institute on Drug Abuse. The Substance Abuse and Mental Health Services Administration. National Center on Substance Abuse and Child Welfare.