Substance Abuse Parenting Evaluations Evaluating Substance Abuse allegations and the Effects of Substance Abuse on Parenting

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1 Substance Abuse Parenting Evaluations Evaluating Substance Abuse allegations and the Effects of Substance Abuse on Parenting Sponsored by OurFamilyWizard.com WHAT IS GOING ON IN THE BRAIN? 1. There are sections of the brain which can be referred to as pleasure centers. 2. The neurotransmitter Dopamine is involved in the stimulation of these pleasure centers. Rutherford, Potenza & Hayes (2013) In Parenting and Substance Abuse 1

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4 Preparing for becoming a parent 1. Anticipation: positive, negative or neutral 2. Expectations of becoming a parent 3. What are the effects of substance abuse on anticipation and expectations? 4. Substance Abuse alters perceptions, anticipation and expectations. 5. Substance abuse interferes with increased growth of gray matter in expectant mothers. Normal mothers show an increase of gray matter whereas substance abusing expectant mothers do not. MOTIVATIONS FOR SUBSTANCE ABUSE 1. REWARD 2. AVOIDANCE AND RELIEF OF UNPLEASANT THOUGHTS AND FEELINGS. 3. POSITIVE REINFORCEMENT AND NEGATIVE REINFORCEMENT 4. INCREASE IN STRESS CAUSES AN INCREASE IN CRAVINGS 5. SUBSTANCE ABUSING PARENTS HAVE A DECREASED REACTION OR LESS OF A HIGH THAN A PARENT WHO DOES NOT ABUSE. 6. SUBSTANCE ABUSING PARENTS HAVE AN INCREASED REWARD RESPONSE TO CUES OR TRIGGERS MOTIVATIONS FOR SUBSTANCE ABUSE 1. REWARD 2. AVOIDANCE AND RELIEF OF UNPLEASANT THOUGHTS AND FEELINGS. 3. POSITIVE REINFORCEMENT AND NEGATIVE REINFORCEMENT 4. INCREASE IN STRESS CAUSES AN INCREASE IN CRAVINGS 5. SUBSTANCE ABUSING PARENTS HAVE A DECREASED REACTION OR LESS OF A HIGH THAN A PARENT WHO DOES NOT ABUSE. 6. SUBSTANCE ABUSING PARENTS HAVE AN INCREASED REWARD RESPONSE TO CUES OR TRIGGERS 4

5 PARENTING IS BOTH REWARDING AND STRESSFUL 1. If Substance abuse decreases the sensation of reward, then parenting is less rewarding. This has an effect on how the parent responds to a child showing rewarding or positive behaviors. 2. The normal stress of parenting is likely to increase triggers or cravings within substance abusing parents. Drug seeking behavior has to interfere with parenting responsibilities. Rutherford, Potenza & Hayes (2013) in Parenting and Substance Abuse WHAT IS MORE REWARDING: ANTICIPATION OR THE ACTUAL RESPONSE TO THE DRUG: 1. Substance abusing parents are more likely to feel a positive effect to the cues or triggers than the drug itself. 2. Classical Conditioning is one way of explaining this effect. 3. In a study of marijuana users who volunteered for a PET scan of their brains while using marijuana, subjects with a family history of abuse or addiction showed more of a response to cues and triggers than subjects without such a history. 4. The theory of Habituation may explain why anticipation beats the real thing. Lucas, Scott E. Presentation 3/6/15 Treating the Addictions: Harvard Medical School SUMMARY 1. Due to lack of gray matter growth, substance abusing parents are less prepared for parenting than normal parents. 2. Substance abusing parents may not anticipate as much the potential joys of parenting as compared to normal parents 3. Substance abusing parents are more likely to experience distress given the expected stressors of parenting. 4. Therefore substance abusing parents may not be as effective with the skills of attachment as normal parents 5. With cocaine using mothers, there was less attentiveness and involvement with their infants and children. 5

6 PARENTING CHALLENGES 1. Warmth and then more warmth 2. Stress and then more stress 3. Stress leads to the secretion of the hormone cortisol 4. Secretion of cortisol is a contributor to cravings 5. Successful parents use many methods to regulate their thoughts, feelings and reactions to the stress involved in parenting. 6. Substance abusing parents want to avoid all stress and struggle more with self control. Rutherford, Potenza & Mayes (2013) in Parenting and Substance Abuse MORE REACTIONS TO STRESS 1. Substance abusing parents are less likely to engage with infants and are more passive. 2. In response to cries and various faces, substance abusing mothers showed less brain activity than normal mothers. 3. In substance abusing parents use more strategies to avoid stress and negative states via using which strengthens addiction. 4. Normal parents use many strategies with crying infants whereas substance abusing parents are more limited. 5. With alcoholic parents, there is a decrease in the volume of the amygdala which is associated with increased cravings. With cocaine the decrease in Gaba may explain cocaine cravings or is it the decrease in dopamine? Rutherford, Potenza & Mayes (2013) In Parenting and Substance Abuse. Also Lukas, Scott E March 6, 2015 Presentation Treating the Addictions, Harvard Medical School CONTINUED EFFECTS OF STRESS: 1. The effects of stress on substance abusing parents decreases activity on the areas of the brain associated with self control while increasing activity of the brain associated with reward, thus the decreased skills and the need for reward or relief from stress. 2. No surprise that substance abusing parents report more stress from parenting than normal parents. 3. Stress is a major factor in relapse in abstinent parents 4. So there is a relationship between reward, stress and craving 5. Cues from children are either ignored or inappropriate (abuse) 6. Quality of parenting does vary in addicted parents, some do well Rutherford, Potenza & Mayes (2013) In Parenting and Substance Abuse 6

7 REACTIONS TO STRESS IN ADDICTED PARENTS 1. Cocaine addicted mothers showed an increase in craving, behavioral arousal and negative emotions when stressed. 2. Alcoholic mothers showed an increase in negative emotions and cravings in reaction to stress 3. All substance abusing parents showed a decreased ability to control impulses and emotions. 4. Stress causes an increase in relapse rates 5. Decreases quality of thinking, planning and strategizing Rutherford, Potenza & Mayes (2013) in Parenting and Substance Abuse BEHAVIORAL PARENTING RESPONSES: 1. Parents may respond to infant cries in 2 ways: 2. Distance or ignore the crying such as use a pacifier. Cocaine addicted mothers much less responsive to a child s cry. 3. Abuse the child due to overreacting 4. Addicted parents of older children who act up may use more drugs at such times. 5. This is a vicious cycle as it is likely substance abusing parents are more likely to have children who act up so the more the parents uses the more the child may act up. Substance abusing women seem to be more affected by stress Chaplin, Tara M and Sinha, Rajita (2013) in Parenting and Substance Abuse MORE REACTIONS 1. Addicted parents are more impulsive in the way they react to children. 2. Addicted parents are more reactive, emotionally or physically 3. More likely to be depressed 4. More likely to be anti social 5. Parents who use alcohol, cocaine and marijuana are less responsive to infants. 6. Similar findings with school age children 7. Alcoholic parents show lower parental warmth Chaplin, Tara M and Sinha, Rajita (2013) in Parenting and Substance Abuse 7

8 PARENTING EFFECTS WITH OLDER CHILDREN 1. Alcoholic parents showed fewer skills such as negotiating and problem solving with adolescent children. 2. Such parents are unable to teach children how to control and regulate their emotions or teach social skills. 3. Increased mother child conflict with older children 4. Overall children of substance abusing parents were twice as likely to be removed from the home. 5. For children of all ages, there is an increased likelihood for physical and sexual abuse when there is a substance abusing parent. Chaplin, Tara M and Sinha, Rajita(2013) in Parenting and Substance Abuse ADDICTION AND PUNISHMENT 1. Substance abusing mothers more likely to be punishing. 2. More use of severe discipline 3. Try to use blind authority 4. Alcoholic father showed more negative parenting styles and more over reactive styles Chaplin, Tara M and Sinha, Rajita(2013) in Parenting and Substance Abuse OTHER CONSEQUENCES 1. Cocaine addicted mothers had children who spent twice as much time in foster care than non cocaine addicted mothers. 2. Parents who have lost their children show an increase in using and homelessness. 3. Opiate addicted mothers self reported poorer parenting 4. Overall many addicted mothers have a history of being abused or neglected in their own childhood. 5. Addicted parents need treatment to become and remain sober, handle stress and learn to be more effective parents. Chaplin, Tara M and Sinha, Rajita (2013) in Parenting and Substance Abuse 8

9 CAUSES OF PARENTING DIFFICULTIES 1. Maladaptive Parenting Behaviors 2. Emotional and relational behaviors in the parent child relationship 3. With addicted parents there is the negative component of parental impulsiveness. 4. Impulsive parents react quickly without forethought or the consequences of their impulsive behavior 5. Impulsivity has a range of different behaviors 6. Substance abuse limits quality of thinking 7. Thinking becomes all or nothing Matusiewicz et al (2013) In Parenting and Substance Abuse REWARDS 1.When addicted parents are not rewarded by a child s behavior, they will seek other rewards such as drugs so they neglect parenting. 2. Due to habituation, rewards may be perceived as less rewarding, especially drug use. 3. Rewards are most often sought by feelings of negative emotions such as low mood, anxiety or anger. 4. So the purpose of an impulsive decision is to decrease the effects of the negative feelings. 5. Addicted parents are low on cognitive resources such as will power, self control and ego strength. 6. Low resources means less adaptive coping skills so therefore more impulsiveness. Matusiewicz et al (2013) in Parenting and Substance Abuse CAUSES OF PARENTAL SUBSTANCE ABUSE 1. Genetics 2. Twin studies, identical twins and fraternal twins 3. Genetics may explain about 70% of substance abuse 4. What about the overlap between genetics and the environment? 5. Diathesis Stress Model 6. Genetics wins when it comes to explaining drug abuse as children of drug abusing parents are about 8 times more likely to have drug abuse problems. Beekman, Charles and Neiderhiser, Jenae (2013) in Parenting and Substance Abuse 9

10 GENETICS AND PARENTING 1. Children who come from a home in which both parents are abusing are more likely to experience poor parental treatment such as abuse or neglect. 2. Young adult children of an alcoholic parent are more likely to become abusive drinkers 3. Parental drug abuse predicts child protective services 4. Children of an alcoholic father are more likely to experience lower levels of maternal warmth, poorer attachment to both parents. 5. At age one children of an alcoholic father receive more negative treatment from their parents and at age 2 the parents showed less positive involvement with their children. Beekman, Charles and Neiderhiser, Jenae (2013) in Parenting and Substance Abuse MORE PARENTING EFFECTS: 1. By age three children of an alcoholic showed showed lower abilities to control their feelings and behavior. Such children were more likely to blame others and have problems in kindergarten with social interaction. 2. Alcohol abusing fathers create so much chaos and difficulty within a family that both parents subsequently struggle to be effective and warm parents. Accordingly children do not develop as well as in a normal family. 3. By age 8 12 children of a drug abusing parent were more likely to struggle with depression, anxiety and behavioral problems. 4. The same is true for cocaine and opiate abusing parents. Beekman, Charles and Neiderhiser, Jenae (2013) in Parenting and Substance Abuse REASONS WHY ADDICTED PARENTS ARE IMPAIRED AS PARENTS 1. There is a lack of knowledge about how to parent. 2. Addicted parents may have come from addicted parents 3. Addicted mothers showed unresponsive and negative parenting during middle childhood. WHY? Think of the difference between a toddler and a school age child in the way they relate to parents. 4. Cocaine abusing mothers were harsh with their children and their children faced more changes in who took care of them plus had less frequent access to male caretakers. 5. Cocaine mothers were less responsive to children at 1,6 and 18 months causing attachment problems. When cocaine mothers perceived their children to be more reactive, the mothers were less sensitive. 10

11 HOW DOES THIS ALL LEAD TO SUBSTANCE ABUSE? 1. Drug addicts cannot tolerate painful feelings. 2. Drug addicts have a hard time describing feelings 3. Instead of emotional feelings, drug addicts feel a bodily need for drugs. The drug is used to stop the need. 4. Drug addicts may feel empty, stating there is nothing inside them 5. Drugs make people feel less empty 6. The sense of emptiness originates in the problems the child has being attached to the parent. 7. Keep in mind this is a two way street as the child who feels unattached does not provide much positive behavior to the parent who then feels rejected by the child. Lyden, Hannah M and Suchman, Nancy E. (2013) in Parenting and Substance Abuse SUBSTANCE ABUSING FATHERS 1. Much has been said and written about substance abusing mothers and how poor attachments lead to substance abuse. What about the role of substance abusing father s? 2. What is a good father? 3. Just as children need to be attached to their mothers, they need to be attached to their fathers. 4. About 42% of men report some substance abuse problem in their life. 5. 8% of 32 million fathers had used something in the past 30 days 6. 59% of fathers with a substance abuse problem were living with their children. McMahon, Thomas J. (2013) in Parenting and Substance Abuse SUBSTANCE ABUSING FATHERS CONT. 1. Almost 12 percent of all children are living with a substance abusing parent or caretaker (SAMSHA) 2. 60% of men in a Methadone Program were fathers 3. Men are more likely than women to be separated from their children. 4. Substance abusing men reported having family problems when they were children. 5. When men are early substance abusers they have more sexual partners and more surprise children. Relationships with women are unstable. 6. Substance abusing men are more likely to marry early and have a partner with various psychological problems. McMahon, Thomas J. (2013) in Parenting and Substance Abuse 11

12 MORE OF THE SAME ISSUE: 1. Marriages are likely to be unstable and have more conflict especially if the wife is not using. Substance abusing fathers are more likely to have affairs. They are more likely to have more children with different women. It is hard for such men to be good fathers and remain good fathers. 2. Substance abusing fathers can have a relationship with a pre school child but overall such fathers have a negative attitude towards parenting and more negative emotions when dealing with children plus a shakier attachment with children. 3. Paternal alcoholism is associated with less family harmony during adolescence and less positive emotions and less problem solving skills with adolescent children. McMahon, Thomas J. (2013) in Parenting and Substance Abuse DRUG ABUSING FATHERS: 1. Drug abusing fathers had a narrow and more traditional view of parenting. 2. More likely to physically abuse children 3. Less likely to be living with their youngest biological child 4. Less likely to be a legal guardian and less likely to pay support 5. Poorer father child communication 6. Poorer father child relationships 7. More parenting stress McMahon, Thomas J. (2013) in Parenting and Substance Abuse MARITAL OR RELATIONAL CONFLICT 1. Positive co parenting is very good for children 2. Parental conflict has a negative effect on development of children 3. With parental conflict men are more likely to withdraw from their children 4. So substance abuse is likely to decrease co parenting and lead to more parental conflict and more aggression between parents 5. Paternal substance abuse is associated with decreased family functioning, poor communication, less organization and consistency 6. Compared with alcoholic fathers, drug abusing fathers reported more troubles with discipline and less monitoring of children. 7. Alcoholic fathers more likely to physically abuse children whereas cocaine addicted fathers were more likely to sexually abuse their children. McMahon, Thomas J (2013) in Parenting and Substance Abuse 12

13 MARITAL OR RELATIONAL CONFLICT 1. Positive co parenting is very good for children 2. Parental conflict has a negative effect on development of children 3. With parental conflict men are more likely to withdraw from their children 4. So substance abuse is likely to decrease co parenting and lead to more parental conflict and more aggression between parents 5. Paternal substance abuse is associated with decreased family functioning, poor communication, less organization and consistency 6. Compared with alcoholic fathers, drug abusing fathers reported more troubles with discipline and less monitoring of children. 7. Alcoholic fathers more likely to physically abuse children whereas cocaine addicted fathers were more likely to sexually abuse their children. McMahon, Thomas J (2013) in Parenting and Substance Abuse HOW CHILDREN ARE AFFECTED BY ADDICTED PARENTS 1. Increased risk of being abused neglected which can develop into academic, emotional, physical and social problems. 2. It is hard to say which drug may lead to these effects given most substance abusers use more than one drug. 3. Pre natal exposure to drugs is thought to be less damaging than the early parenting environment the children experience Kaltenback, Karol (2013) in Parenting and Substance Abuse PRENATAL EXPOSURE 1. Alcohol can cause FAS or fetal alcohol syndrome causing physical, intellectual, emotional growth and is associated with MR. 2. Marijuana, cocaine and opiates may cause premature birth, low birth weight, decreased head size and miscarriage 3. These newborns are at risk for Neonatal Abstinence Syndrome which can be compared to withdrawal with such symptoms of weight loss, tremors, mood swings, vomiting and diarrhea. Salo, S and Flykt, M (2013) in Parenting and Substance Abuse 13

14 EXPOSURE TO SUBSTANCE ABUSING PARENTS 1. Children more likely to have physical, emotional and intellectual problems. 2. Poor attachment 3. Opioid using mothers scored the lowest in warmth, structure and non intrusiveness. They are less positive with children. 4. Cocaine mothers showed more negative engagement with their children. They were less attentive and less engaged. 5. So called difficult children fared the worse. Salo, S and Flykt, M (2013) in Parenting and Substance Abuse INTELLECTUAL FACTORS 1. Prenatal use of marijuana does not impair IQ but is predictive of lower academic achievement. 2. Prenatal use of cocaine did reveal deficits in IQ by age 7 along with delays in language development. 3. Opioid abuse was associated with lower IQ with very young children. 4. However what could also cause deficits is the environment the child is raised in. Children living in poverty also show deficits. When environments were improved, children caught up. Salo, S. and Flykt, M (2013) in Parenting and Substance Abuse ATTENTION AND EMOTION 1. Prenatal marijuana use has an effect on executive functioning, attention and visual analysis. Some children also exhibit poorer self regulation and increased impulsiveness. 2. Prenatal cocaine children also showed similar effects but were also more likely to experience stress. These children are less positive and show more negative behaviors to their mother. Some had difficult temperament, emotional problems and behavioral problems. 3. Prenatal opioid use is associated with increased impulsivity and attention problems. Salo, M and Flykt, M (2013) in Parenting and Substance Abuse 14

15 BEHAVIORAL EFFECTS 1. Children of cocaine using mothers were more likely to be aggressive and show less empathy and compassion. These children were less concerned about hurting others. These children saw social interactions as being stressful. 2. Children of substance abusing parents are more likely to have conduct disorders, mood disorders, engage in anti social behaviors and develop substance abuse problems % of cocaine and opiate abusing mothers had a psychological disorder by age 12. About half of children admitted to hospitals had histories of parental substance abuse. Salo, S and Flykt, M (2013) In Parenting and Substance Abuse MORE EFFECTS 1. Children living with drug abusing fathers at the ages of 8 12 were more likely to have a lifetime psychological diagnosis. These would include anxiety, depression and acting out behaviors such as antisocial. 2. Physically abused children had more acting out problems. 3. Very important to try to differentiate the substance abuse and the overall environment the child grows up in plus genetics. 4. Good news, children who received family based therapeutic intervention did improve over time. Salo, M and Flykt, M (2013) in Parenting and Substance Abuse THE NUTS AND BOLTS OF A SUBSTANCE ABUSE EVALUATION WITH PARENTS: TWO MAJOR QUESTIONS 1. Is there a substance abuse problem? 2. Does the substance abuse negatively interfere with parenting and how? 15

16 DATA COLLECTION Interviews with parents Interviews with children Medical and Psychological records/treatment records CORI records CPS records Police reports Work history Collateral witnesses Professional Witnesses Testing both psychological and drug/alcohol screens Work reports Pharmacy reports Family Court records Unannounced home visits SPECIFIC SUBJECTS FOR INQUIRY 1. Start with a brief personal history 2. Ask about family history 3. Ask about a personal history of experiencing neglect and abuse 4. As about trauma 5. Ask about educational, employment and health/psychological history 6. Ask about relationship history/parenting history 7. Ask about a history of violent behavior, criminal behavior, CPS history and Family Court involvement 8. Ask if substance abuse was a factor in any area of history SUBSTANCE ABUSE QUESTIONS FOR EACH SUBSTANCE 1. When was the first use, how much was used at the time/what were the effects. 2. How often thereafter was the substance used, how much and how often/what were the effects. Example: If a parent has been using any substance for many years, ask about the first four years, the second etc. When did the parent increase use and frequency of use/what would explain any changes. 3. When was the last time the substance was used? When does the parent anticipate using again? What would trigger further use? Are there any urges and cravings? How often are there urges and how strong are the urges? What does the parent do to respond to urges and cravings 16

17 More Questions What does the parent like about using the substance? Under what conditions would the parent continue to use? Has the parent ever stopped using? For what reasons? What were some of the negative effects of using How would the parent benefit if the parent stopped using? If the parent stopped using, what would the parent miss about using What effects would further use have on parenting What effects would abstinence have on parenting? SPECIFIC QUESTIONS ABOUT ALCOHOL USE 1. When asking about having a drink, ask about the type of alcohol. Keep in mind one drink is defined as one 12 ounce beer, or one ounce of hard alcohol or 5 ounces of wine. 2. How much does it take to feel a buzz? 3. How much does it take to feel intoxicated? 4. What are hangovers like 5. Safe social drinking for men is no more than 14 drinks a week and 7 drinks a week for women. SPECIFIC QUESTIONS ABOUT DRUGS: Asking about drug use is harder as users do not measure how much marijuana is in a joint or a pipe. Users cannot measure how potent the drug is. Lines of cocaine can vary in width and length along with potency. It is hard to measure how much cocaine is inhaled if smoking cocaine. Opiate use is similar as parents are unlikely to carefully measure how much is snorted or injected or know the potency of the drug. Prescription opiate use can be measured in milligrams and how many pills taken how often. 1. The parent can be asked how often the substance is used, the last use of the substance and general questions. EX: How many joints are used in a day or how often does a person do lines or inhale or how often does a person snort or inject heroin. 17

18 OVERVIEW ON INTERVIEWING PARENTS 1. Ask all these questions about each drug used throughout the parent s life. 2. Then ask parenting questions with specific emphasis on the age of the children involved. EX: How does the parent respond to infant cries when the parent has been using? EX: How does the parent react to infant cries during an urge or craving to use? The same can be asked about any parenting situation of any age children. Ask about discipline, chores, homework, use of electronics, the use of affection, play, activities etc. INTERVIEWING SOBER OR RECOVERING PARENTS 1. Follow the same procedures used to interview parents suspected of substance abuse. 2. Length and strength of sobriety This refers to how long the parent has been clean and sober. This means no use of alcohol, marijuana, any illegal drugs and abuse of prescription medications. Strength means what is the parent doing to maintain being clean and sober. 3. Ask the parent what their reasons were for becoming abstinent? 4. Ask about the benefits of being clean and sober. 5. Ask about the disadvantages of being clean and sober or what does the parent miss about using? MORE QUESTIONS: What would trigger the parent to use again? How does the parent handle urges and cravings What is the parent willing to do to probe being clean and sober What changes has the parent experienced being clean and sober What has been the effect of being clean and sober on parenting their children? What does the parent think the children experienced when the parent was using? What improvements in parenting would be good for the children 18

19 QUESTIONS ABOUT TREATMENT If the parent attends AA or NA ask the following: 1. How often does the parent attend meetings 2. What meetings does the parent attend 3. What type of meetings are attended 4. Does the parent volunteer at meetings? 5. Where does the parent sit? 6. Does the parent have a sponsor 7. Is the parent working the steps of recovery 8. What steps are being worked on currently 9. What else does the parent want to do to pursue and strengthen and maintain recovery MORE QUESTIONS: If the parent is attending Smart Recovery as the following: 1. How often does the parent attend meetings? 2. What meetings does the parent attend 3. How active is the parent during these meetings 4. What is the parent learning in meetings 5. To what extent is the parent helping others 6. What are the parents learning about parenting THERAPY QUESTIONS 1. Is the parent in individual therapy, group or both? 2. How often do sessions occur 3. What are the goals of therapy 4. What progress has the parent made while in therapy 5. What further progress does the parent want to make 6. How helpful is the therapy? 7. If group therapy to what extent does the parent contribute? 8. What effect does therapy have on abstinence 9. What is being learned about parenting in therapy 19

20 DRUG THERAPY OPTIONS The major drugs used for abuse and addiction are Suboxone, Methadone, Naltrexone and Vivitrol. As many substance abusing parents have cooccurring psychological problems, anti depressant, anti anxiety and mood stabilizing drugs have been prescribed. Medications for sleep are prescribed. Vivitrol is a once a month injection which is supposed to block cravings and urges and the effects of opiates. Naltrexone is a pill that helps with urges and cravings. Suboxone is a pill and Methadone is usually given in a drink form. Suboxone and Methadone are thought to block the effects of opiates or decrease urges and cravings. Methadone therapy can be methadone maintenance or methadone detox. Methadone clinics require daily attendance, some form of therapy and drug testing. DRUG THERAPY QUESTIONS 1. If Methadone, how often does the person attend the clinic? Is the treatment for maintenance for detox. What counseling is being attended? What are the results of the drug testing. How helpful is the treatment? What is hard about treatment. 2. For Suboxone ask how many pills are prescribed at one time. Are the pills being counted? Is any therapy being administered as part of the treatment? How helpful is the treatment? What is hard about treatment. 3. For Vivitrol ask how often is the injection given. Ask about therapy being used if any. How helpful is the treatment and what is hard about it. Same questions about Naltrexone. INPATIENT DETOX AND RECOVERY PROGRAMS These inpatient programs vary in length and intensity. Some are publicly funded while others are very expensive. In the 1980 s and 1990 s these programs were generally 28 day programs covered by insurance. The private and expensive programs are about 30 days in length. A public detox may be three days to a week. There are some public longer term programs, some lasting as much as a year. Finally there are day treatment options which generally last a week or two. Some are public and free of charge, others are likely covered by insurance. SAMSHA 20

21 PRESCRIPTION DRUG RECORDS 1. Records should be requested from every pharmacy the parent may access. 2. Pharmacy records can be lengthy and need to be re organized. 3. The use of a spread sheet (Excel) is excellent for organizing the prescription records via date and dosage for each drug. 4. A friendly and neutral physician can review the spread sheet (without identifying identification) to give an opinion of the frequency and dosage of each drug 5. The prescribing physician can be called to give opinions of the parent has used the drug as prescribed. 6. When reviewing these records, look for inconsistencies in the use of refills and dosages. PSYCHOLOGICAL TESTING 1. Some psychological tests have some scales measuring substance abuse problems. Example MMPI 2, MCMI 3 and Psychological tests are rated on measures of reliability, validity and the use of validity scales. 3. Reliability means test results should remain consistent over time. Validity determines if the test measures what the test claims it measures. 4. Validity scales are used to determine how a person responds overall to the test, is the parent open, defensive or truth challenged. 5. Test results can be used to detect a substance abuse problem or the test may detect psychological problems that are associated with substance abuse. SUBSTANCE ABUSE PAPER TESTS 1. There are very good tests available such as the MAST and the SASSI. 2. These tests are entirely dependent on the parent being open and cooperative with the test. 3. Some tests claim to detect denial, minimizing and lying. 4. Substance abuse evaluations should never be entirely or heavily based on the results of these tests. 21

22 DRUG AND ALCOHOL TESTING 1. Testing is conducted with samples of urine, blood, breath, saliva, skin conductivity or hair. 2. Tests that measure breath measure for alcohol use. These include the breathalyzer, the interlock device and Soberlink. Tongue strips are available at most modern pharmacies as are breathalyzer devices. 3. Most drug tests involve urine, blood or hair. Urine tests are most accurate when the parent being tested is observed urinating into a cup. Urine tests measure if a parent has consumed too much water or other substances designed to make a positive result appear negative. MORE ABOUT DRUG AND ALCOHOL TESTS 4. Urine tests can detect alcohol if the parent has been drinking recently. A urine ETG test can detect moderate to severe alcohol use during the three days preceding the test. 5. A urine test can detect drug use (with the exception of MJ) for the past three days. Marijuana can be detected in urine for up to 30 days prior to the test. Urine testing is most accurate if administered on a random basis. 6. Hair follicle tests can detect drug use 90 days prior to the test. There has been some controversy about hair follicle tests given different hair in different races and cultures. Possibly hair follicle test results may be altered by various substances placed on hair. 7. In the Massachusetts Probate and Family Courts, testing can be administered in Court the same day with results the same day. IMPORTANCE OF DRUG AND ALCOHOL TESTS 1. A substance abuse evaluation is glaringly incomplete without a very recent drug and alcohol test. 2. These tests should be used even with parents who claim to be recovering and/or abstinent. 3. Testing should be used for as long as necessary to help determine if a parent should have access to a child and to monitor abstinence while a parent has ongoing access to a child. 4. Interlock and Soberlink devices should be strongly considered for parents who are planning to drive while with their children. 22

23 PROBLEMS WITH ALCOHOL AND DRUG TESTS 1. Drug tests detect the presence of a substance. Tests usually do not indicate the dosage or amount of drugs in the system. 2. If a parent has a prescription for an anxiety medication, an ADHD medication or an opiate painkilling medication, test results cannot state if the medication is being taken as prescribed. 3. Test results may be inaccurate so there can be false positive and false negative test results. Sometimes test results of the hair follicle test may not be consistent with urine test results. 4. Parents may have creative excuses for missing a drug test. In Massachusetts the failure to appear for a test is interpreted as a positive test result. CONCERNS ABOUT RELAPSE Relapse is unfortunately common. Some would say relapse is a part of the recovery process. Increased efforts by a parent to remain sober can decrease likelihood of relapse but there is no known method to confidently predict who will relapse and when. A substance abuse evaluation should inform the Court of the actions the Court may consider should a relapse occur. The Court may consider a suspension of access to the child or the use of supervised visits. In addition the evaluation should make treatment recommendations in the event of relapse. AA/NA AS TREATMENT OPTIONS step programs are free. In most communities there are meetings often on a daily basis night and day. 2. Meetings can be located by going online or there are free meeting lists Step programs offer the opportunity to be with others who are either striving to achieve sobriety or are maintaining sobriety step programs offer hope plus a constant reminder of the risks of substance abuse step programs offer free sponsors or recovery coaches who can be accessed on a daily basis. 23