Understanding Substance Abuse and Facilitating Recovery …centerforchildwelfare.fmhi.usf.edu/kb/CWP/subabuse/su… · · 2010-02-09Understanding Substance Abuse and Facilitating

Children at RiskUnderstanding Substance Abuse

and Facilitating Recovery

A Guide for Child W lf W kWelfare Workers

Darran M. Duchene, MSW, MPSADirector, Treatment Services

Substance Abuse Program Officeg

S i T i i G l !Seminar Training Goals……!

Identify the impact parental substance abuse has on children.

Recognize when substance abuse is a factor in child welfare.welfare.

Understand signs and effects of addiction.

Help understand and facilitate treatment and recovery.

Understanding Substance Abuse and Facilitating Recovery: A Guide for Child

Welfare Workers (2004)

S i T i i G l !Seminar Training 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 dand recovery.



Child t Ri k !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.



Effects of ParentalEffects 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. E i i t bilit Economic instability. Parental incarceration. Higher risk for entering foster care Higher risk for entering foster care.

Child Welfare and Substance AbuseErica Tarasovitch, MSW

Effects of Parental SubstanceEffects of Parental Substance Abuse on Child Development

Physical health consequences. Lack of secure attachment. Language delays and communication disorders. Psychopathology. B h i l bl Behavioral problems. Poor social relations and skills. Deficits in motor skills Deficits in motor skills. Cognition and learning disabilities.


A Child’ P i t f ViA Child’s Point of View



Effects of ParentalEffects of Parental Substance Abuse Parenting Unclear expectation for behavior. Poor monitoring of behavior. Inconsistent minimal rewards for behavior. Inconsistent discipline. O d i l t ith hild Over or under involvement with children. Lack of bonding or closeness with family members. Family conflict or lack of involvement in family Family conflict or lack of involvement in family

activities.

Linda Mann, MSW, LCSW, CAP

Domestic Violence andDomestic 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.


Legal Standards for When SubstanceLegal 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 WelfareChild 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.



Wh t i Addi ti ?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.


Addiction is a Family DiseaseAddiction 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.


Si f Addi tiSigns 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.



P h l i l Addi tiPsychological Addiction

People Need Alcohol or Drugs To:Relax…Feel good…Reward themselves…Positive alcohol expectancies…Avoid feeling worseAvoid feeling worse…Function as a parent…To reduce guiltTo reduce guilt…



CW St ff M t C idCW 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.



UnderstandingUnderstanding Use/Abuse/Dependence.

Substance use occurs along a continuum:Experimental…..pSocial…..Moderate…..High-Risk…..AbuseAbuse…..Dependence =Addiction =Alcoholism



DiagnosingDiagnosing 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 homeobligations at work, school, or home.

Recurrent use in situations which areRecurrent use in situations which are physically dangerous like operating equipment or driving a car.



DiagnosingDiagnosing Substance Abuse

At least ONE of these factors in the past 12 months:

Recurrent substance-related legal problems.

Continued use despite social and interpersonal problemsinterpersonal problems.



DiagnosingDiagnosing Substance Dependence

Substance Dependence: 3 or more factors in the past 12 months

Tolerance: needing more of the substance to get “high”get high .

Withdrawal: physical and psychologicalWithdrawal: physical and psychological symptoms.





More of the substance is taken over a longer period than was intendedperiod than was intended.

Unsuccessful efforts at cutting down orUnsuccessful efforts at cutting down or controlling substance use.





Great deal of time is spent obtaining the substance or recovering from its effects.

Social, occupational, or recreational activities are given up.




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.



Parental Addiction IncreasesParental Addiction Increases Risks for Children

Use during pregnancy can harm the fetus.Misuse/abuse of prescription pain p p p

medications.Driving with children in the car while under

th i flthe influence.Children may be left in unsafe care while

parent is partying or buying drugsparent is partying or buying drugs.Other caregivers including grandparents can

poise a serious risk to children.p



Parental Addiction IncreasesParental 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 childrenparent s use may leave children unsupervised.

Behavior toward children may be inconsistent, such as a pattern of violence , pthen remorse.



Women andWomen and Substance Abuse

Less alcohol for women to get intoxicated.

Women progress to addiction in less time than men.

Many have experienced physical or sexual y p p yabuse in childhood.



Women andWomen 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.



Parental Substance Abuse: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.



Is Substance AbuseIs 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.



In-Home Examination forIn 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., j , g

Child reports parental use.C p pUnderstanding Substance Abuse and

Facilitating Recovery: A Guide for Child Welfare Workers (2004)


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.




A parent shows or reports experiencing physical effects of addiction.

Shows or reports signs of tolerance or withdrawal.

Observe persons who frequent the home.



Best Practices: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.



Wh Sh ld b S d?Who Should be Screened?

All adults in the household.

Other adults connected to the case.

Extended family members.

Older children in the home.



S i T l UNCOPEScreening Tools: UNCOPE

U - Have you continued to USE alcohol or drugs longer than you intended? Or havedrugs longer than you intended? Or, have you spent more time drinking or using than you intended?

N Have you ever NEGLECTED some ofN - Have you ever NEGLECTED some of your usual responsibilities because of alcohol or drug use?or drug use?



S i T l UNCOPEScreening Tool: UNCOPE

C - Have you ever wanted to stop using alcohol or drugs but couldn’t? (CUT down)alcohol or drugs but couldn t? (CUT down)

OO - Has your family, a friend, or anyone else ever told you they OBJECTED to your l h l d ?alcohol or drug use?



S i T l UNCOPEScreening 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?g ?

E Ha e o e er sed alcohol or dr gs toE - Have you ever used alcohol or drugs to relieve EMOTIONAL discomfort, such as sadness anger or boredom?sadness, anger, or boredom?



What to Do When Alcohol orWhat 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.



Methamphetamine Use andMethamphetamine 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.associated with methamphetamine production.

Lack of parental supervision contributes to children ingesting contaminated food and chemicals.



Talking With Children AboutTalking 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.



Talking With Children AboutTalking 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.pFind someone you can trust.Many communities have Alateen meetings.y g



C lt l d Eth i S iti itCultural 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.g



B t P ti i T t tBest Practices in Treatment

Employ a recovery perspective.Adopt a multi-problem viewpoint.p p pDevelop a phased approach to treatment.Address real-life problems early in treatment.p yUse support systems to maintain and extend

treatment.Use a motivational approach.Reduce barriers to treatment.

SAMSHA’s Co-Occurring Center for Excellence

D t ifi ti S iDetoxification 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.



Wh T R f f D tWhen 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”.y y



Cli i l T t t S iClinical Treatment Services

Outreach and engagement.

Trauma specific activities.

Screening.Detoxification.

Medical care.Mental health

Crisis intervention.Substance abuse

services.Drug monitoring.

counseling and education.

Continuing care.



Cli i l S t S iClinical Support Services

Primary health care.Life skills.

Linkages with legal system and child

Parenting and child development

welfare system.Housing support.

education.Family programs.

Advocacy.Recovery

Employment readiness services.

community support services.



C it T t t S tCommunity Treatment Support

Recovery management.Family strengthening.Family strengthening.Transportation.Child careChild care.Temporary Assistance for Needy Families.Employer support servicesEmployer support services.Vocational and academic education services.Faith based organization supportFaith based organization support.



St f R ?Stages of Recovery?

Stabilization: detox and enters treatment. Early recovery: insight into understanding the events

h l d ithat led up to entering treatment.Middle recovery: commits to long term treatment

with a recovery plan.with a recovery plan. Late Recovery: addresses major life issues sober and

may begin spiritual journey.Maintenance: Accepts and commits to long term

recovery.



Treatment and RecoveryTreatment and RecoveryIssues Specific to Women

May have low self-esteem, low self-confidence and may feel powerless.

Women appear to become addicted more rapidly than men.

Use of support groups may have greater benefits for women.



Treatment and RecoveryTreatment and RecoveryIssues 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

ltassault.Continuing relationship with treatment

id f d h l f l fprovider found helpful for women.Understanding Substance Abuse and


S lf H l 12 St GSelf-Help or 12 Step Groups

Twelve Step Facilitation Therapy supporting a person’s participation in:

Alcoholics Anonymous (AA)Narcotics Anonymous (NA)AlanonAlateen



How Can You MotivateHow 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 F ili A tFamilies Act.

Website: Adoption.com

What isWhat 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)

EnhancingEnhancing 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 themchange them

( Jacobson & Christensen, 1996)

Brief InterventionsBrief InterventionsFRAMES

Feedback: provide nonjudgmental feedback.Responsibility: encourage client p y g

responsibility.Advise: offer advice.Menu: provide a menu of options.Empathic: be empathic.p pSelf-Efficacy: support self-efficacy.

Tip 34 Brief Interventions and Brief Therapies for Substance Abuse

Four Guiding Principles ofFour 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.g

Support self-efficacy and optimism.S pp y pUnderstanding Substance Abuse and


Brief Interventions For High-Brief Interventions For HighRisk 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.



Li t R fl ti lListen Reflectively

Reflection is the single most important MI skill.

Listen carefully and think reflectively.

Reflect back in a statement what you think yyou heard the client say. Do you mean…?

R di t ChReadiness 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?yDo they view change as too difficult?



Key Readiness toKey Readiness to Change Factors

Perception of need to change.

Belief that change is possible.

Confidence that one can change.

Stated intention to change.



Motivational Strategies forMotivational 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.




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.




Preparation: Parent is deciding and preparing to change.

Motivational Strategies:Review a menu of change options.Develop A Plan for ChangeAssess the strength of client change, talk.g g ,Discuss steps involved in change.Review what has worked with other clients.




Action: I am starting to change.

Motivational Strategies:Help parent implement strategy and steps.p p p gy pListen and affirm client progress and success.Continue to build self-efficacyContinue to build self efficacy.Reaffirm clients’ decision to change.




Maintenance: I am actively working and maintaining long term change.

Motivational Strategies:Identify triggersProvide relapse prevention.A slip is a learning experience.p g pReinforce what’s working.




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.



Provide Recovery SupportProvide 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.support plan worksheets.

Increase positive healthy activities and lifestyles.

Increase involvement in self-help groups.



Defining aDefining 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, p g g ,slips, lapses, relapses and urge surfing.



Recovery Support Plan ToRecovery Support Plan To Prevent Relapse

Parents can plan for safety of their children.Seek healthy ways to avoid and cope with y y p

triggers that reduce risk and harm.Carry an emergency card with your plan of

action. Develop plans for parents to minimize the impact on

th i hildtheir children.



Supporting RecoverySupporting Recovery for Women

Women relapse less than men.

More likely to engage in group counseling than men.

Negative emotions and interpersonal g pproblems are triggers for relapse with women.



Supporting RecoverySupporting Recovery for Women

Regular and frequent visitation with children and planning for their return can enhance motivation for abstinenceabstinence.

Frequent parent-child visits sometimes conflict with Frequent parent child visits sometimes conflict with early treatment restrictions about visitation.

CW and SA providers should develop a collaborative case plan.



Barriers toBarriers to Treatment for Women

Transportation.Safety of children and childcare.yHealth.Strained interpersonal relationshipsp pFinancial stressors.Prior traumaPrior trauma.Domestic violence.Partners who still usePartners who still use.



Cross-SystemCross 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.



Research on EffectiveResearch on Effective Collaboration

Mutual respect, understanding, and trust.Open and frequent communication.p qPartners see collaboration in their interest.A mutual sense of ownership.pFormal and informal communication.Concrete attainable goals and objectivesConcrete, attainable goals and objectives.



Research on EffectiveResearch on Effective Collaboration

Learn about your partner.Establish a working relationship.g pUnderstand and value each other.Acknowledge boundaries.gSeek supervision.Identify areas of collaborationIdentify areas of collaboration.



Why TreatmentWhy 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.



Why Substance Abuse Providers NeedWhy 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.



Issues and ServicesIssues 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.




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.




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.



Child W lf W kChild Welfare Workers

Explain the development of court reports.

Types of progress information needed for child welfare case plans.

Treatment and recovery progress y p ginformation.



Child W lf W kChild Welfare Workers

Share permanency plans.What is the permanency plan for the child?p y pWhat is the goal for reunification?What is the optimal parent/child visitation p p

schedule?Is there a concurrent plan?p



Areas to Include inAreas to Include in Collaboration

Assess what the children and family needs. Provide contact if on a waiting list. Case planning 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.



RResources

The Administration for Children and Families. The National Institute on Alcohol Abuse and

Al h liAlcoholism. The National Institute on Drug Abuse. The Substance Abuse and Mental Health Services The Substance Abuse and Mental Health Services

Administration. National Center on Substance Abuse and Child

Welfare.



Documents

Understanding Substance Abuse and Facilitating Recovery …centerforchildwelfare.fmhi.usf.edu/kb/CWP/subabuse/su… · · 2010-02-09Understanding Substance Abuse and Facilitating