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ADDRESSING CO-OCCURING DISORDERS IN SUBSTANCE EXPOSED CHILDREN Clinical Considerations Presenters: Ira J. Chasnoff, M.D. Arthur Krzyzanowski, Psy.D. Children’s.

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Presentation on theme: "ADDRESSING CO-OCCURING DISORDERS IN SUBSTANCE EXPOSED CHILDREN Clinical Considerations Presenters: Ira J. Chasnoff, M.D. Arthur Krzyzanowski, Psy.D. Children’s."— Presentation transcript:

1 ADDRESSING CO-OCCURING DISORDERS IN SUBSTANCE EXPOSED CHILDREN Clinical Considerations Presenters: Ira J. Chasnoff, M.D. Arthur Krzyzanowski, Psy.D. Children’s Research Triangle

2 The Children of Substance Abusing Mothers Either: o Have been prenatally exposed to alcohol and/or drugs and have been diagnosed with FAS/FASD; o Are suspected of having been prenatally exposed, but have not been formally diagnosed; o Have no evidence of prenatal substance exposure. © Children’s Research Triangle 2004

3 Prenatal Substance Exposure According to a recent study:*   40,000 children/year are diagnosed with FAS   Still, 95% of children with FAS go undiagnosed NOTE: A negative toxicology screening at birth does not mean there was no prenatal alcohol/drug exposure.  * Lupton, C., Burd, L., & Harwood, R. (2004). Cost of Fetal Alcohol Spectrum  * Lupton, C., Burd, L., & Harwood, R. (2004). Cost of Fetal Alcohol Spectrum Disorders. American Journal of Medical Genetics, 127C (1),

4 © Children’s Research Triangle 2004 Diagnostic Considerations Attention Deficit/Hyperactivity Disorder Mood Disorders Behavior Disorders Post Traumatic Stress Disorder Anxiety Disorders Attachment Disorders Language Based Disorders Learning Disabilities Pervasive Developmental Disorders Alcohol/Substance Abuse

5 © Children’s Research Triangle 2004 Treating the Whole Child The emergence of behavioral, emotional, physical and/or social problems in the children we serve is over-determined! The child’s development and functioning are influenced by risk factors stemming from:   The Child   The Parent/Family System   Society/Environment

6 © Children’s Research Triangle 2004 Child Risk Factors   Exposure to Toxins In Utero   Inadequate Prenatal Care   Pre-maturity   Birth Anomalies/Defects   Chronic or Serious Illness   Temperament   Mental Retardation/Low Cognitive Abilities   Childhood Trauma   Insecure Attachments   Anti-Social Peer Group

7 © Children’s Research Triangle 2004 Parental Risk Factors Active Substance Abuse Active Substance Abuse Maltreatment and Trauma Maltreatment and Trauma Parent’s Own History of Loss and Trauma Parent’s Own History of Loss and Trauma Insecure Attachment Insecure Attachment Single Parenthood (With Lack of Support) Single Parenthood (With Lack of Support) Harsh, Inconsistent or Inadequate Parenting Harsh, Inconsistent or Inadequate Parenting Family Disorganization Family Disorganization Social Isolation Social Isolation

8 © Children’s Research Triangle 2004 Parent Risk Factors (Cont.)  High Parental Conflict  Domestic Violence  Separation/Divorce  Parental Psychopathology  Illness  Death of Family Member  Foster Care Placement

9 © Children’s Research Triangle 2004 Social/Environmental Risk Factors o o Poverty o o Lack of Access to Medical Care/Social Services o o Parental Unemployment o o Homelessness o o Inadequate Childcare o o Exposure to racism o o Poor Schools o o Frequent Residence Change o o Environmental Toxins o o Dangerous Neighborhood o o Community Violence

10 © Children’s Research Triangle 2004 Child Protective Factors   Good Health   Personality Factors   Above Average Intelligence   History of Adequate Development   Hobbies/Interests   Good Peer Relationships

11 © Children’s Research Triangle 2004 Parental/Family Protective Factors Secure Attachments Parents Supportive of Child Household Structure, Monitoring, Rules Support/Involvement of Extended Family Stable Parental Relationship Parents Model Competence/Coping Skills Family Expectations of Pro-social Behavior High Parental Education Level

12 © Children’s Research Triangle 2004 Social/Environmental Protective Factors Middle Class or Above SES Access to Health Care/Social Services Consistent Parental Employment Adequate Housing Family Religious Participation Good Schools Supportive Adults Outside of Family

13 © Children’s Research Triangle 2004 Supporting the Children Trans-Disciplinary Approach o o A child’s problems are over-determined, so their treatment needs to be multi-faceted, with risk factors addressed from several directions simultaneously. o o Providers work collaboratively, each bringing their expertise to bear in addressing the child’s needs o o Contrasting the traditional medical model with its reliance on hierarchy (M.D., Ph.D., MSW, OT/PT…) o o No one provider has all the answers. We each hold a piece of the puzzle.

14 © Children’s Research Triangle 2004 Identifying Needs and Accessing Appropriate Services   Appropriate interventions start with accurate and comprehensive assessments   Medical and Psychological Assessment   Academic Achievement   Occupational Therapy   Physical Therapy   Developmental Therapy (Ages 0-3)   Speech/Language Therapy

15 © Children’s Research Triangle 2004 Possible Treatment Providers  Addiction Counselor(s)  Court System  Occupational Therapist  Pediatrician  Physical Therapist  Psychiatrist(s)/Neurologist(s)  Psychologist(s)/Neuropsychologist(s)  Social Worker(s)  Speech/Language Therapist  Teachers/Educational Specialists

16 © Children’s Research Triangle 2004 Intervention Strategies “An ounce of prevention is worth a pound of cure.” Parent’s Recovery (Pregnancy & Post-partum) Parent Education, Training and Support Prenatal and Perinatal Care Early Identification and Intervention Services for the infant/child

17 © Children’s Research Triangle 2004 Maximizing the Impact of Interventions Intervention strategies that: o o address multiple risk factors rather than focusing on only one factor; o o provide the child and family support in a variety of settings; o o work with the family and child over time (2-5 years); and o o are initiated as early as possible in the infant’s life have the greatest potential for positively affecting the outcome of an at-risk child’s development.

18 © Children’s Research Triangle 2004 O-3/Early Intervention Services Medical Medical Developmental Therapy Developmental Therapy Occupational Therapy Occupational Therapy Physical Therapy Physical Therapy Speech/Language Therapy Speech/Language Therapy Social/Emotional Development Social/Emotional Development

19 © Children’s Research Triangle 2004 School-Based Assessments Parent meeting with teachers, administration and associated services Multi-disciplinary team meetings; IFSP and IEP Development and Reviews Academic Assessment Psychological Assessment (including IQ) Speech/Language Therapy Occupational Therapy Physical Therapy Social Work

20 © Children’s Research Triangle 2004 Sensory Integration (SI) Disorder  Deficits in processing and modulating incoming  Deficits in processing and modulating incoming sensory information   FAS/FASD students are more or less sensitive to stimuli   Lower threshold = Easily overwhelmed   Higher threshold = Under-responsive   Treated through Occupational Therapy with a SI focus   Classroom accommodations available to facilitate attention and on task behavior within the classroom

21 © Children’s Research Triangle 2004 Impact of Sensory Processing Problems   May result in considerable agitation and discomfort (both physical & emotional)   May increase distractibility and irritability   Disruptions often lead to impairments in social, emotional and cognitive functioning

22 © Children’s Research Triangle 2004 SI Resources Sensory Integration and the Child  A. Jean Ayres The Out-of-Sync Child: Recognizing and Coping With Sensory Integration  Carol Stock Kranowitz

23 © Children’s Research Triangle 2004 Psychotherapy Treatment Techniques Picking the right therapy for the individual child:Picking the right therapy for the individual child: Attachment TherapiesAttachment Therapies - Theraplay®- Theraplay® - Dyadic Developmental Psychotherapy- Dyadic Developmental Psychotherapy Experiential TherapiesExperiential Therapies Family/Parent-Child TherapyFamily/Parent-Child Therapy Behavior Modification TherapyBehavior Modification Therapy Parent Psycho-educationParent Psycho-education

24 © Children’s Research Triangle 2004 Basic Assumptions of Theraplay ®  Playful, joyful, empathic, attuned responsiveness  Creation of a more positive relationship between children & their parents  Roots of development of self esteem lie in the early years, thus returning to the derailed developmental stage is essential

25 © Children’s Research Triangle 2004 Dyadic Developmental Psychotherapy Daniel A. Hughes PhD o Treatment is directive and client-centered o Parent is present during sessions o Playful interactions focused on positive affective experiences o Nonverbal as well as verbal communication o Exploration of shame with empathy o Co-regulation of affect o Therapist and parent maintain attitude: PACE (Playful, Accepting, Curious, Empathic)

26 © Children’s Research Triangle 2004 Experiential Therapies Self-regulation – Combining Sensory Integration into Psychotherapy Self-regulation – Combining Sensory Integration into Psychotherapy Narrative therapy – Creating a coherent autobiographical narrative for the child Individual/Play Therapy Social Skills Training NOTE: Insight-oriented therapy typically is not effective with this population given concrete cognitive processes.

27 © Children’s Research Triangle 2004 Behavioral Consultation   Identify the problem behaviors   Frequency   Duration   Intensity   Context (Precipitating & Sustaining factors)   Identify the student’s strengths

28 © Children’s Research Triangle 2004 Behavioral Consultation (Cont.)  Concretely define targeted behavior(s) to be eliminated  Identify substitute behavior or required level of performance  Always state behavioral goals in the positive (“Johnny will do…”) rather than the negative (“Johnny will not…”). Be explicit with the child as to the behavior expected.

29 © Children’s Research Triangle 2004 Behavioral Consultation (Cont.)  Develop Preventative and Reactive Strategies to deal with the behavior(s)  Develop a means of assessing behavior change  Assessing consultant effectiveness

30 © Children’s Research Triangle 2004 Parent Psycho-education   Effects of mother’s substance abuse (prenatal and post-partum) on their child’s development   Age-appropriate developmental expectations   Parenting skills for the behaviorally and/or emotionally disturbed child   Advocating for services from the larger community   Structuring child’s environment and effective limit-setting (Acting as an “External Brain”)

31 © Children’s Research Triangle 2004 Involvement in the Criminal Justice System According to a long-term study* of adolescents and adults diagnosed with FASD: According to a long-term study* of adolescents and adults diagnosed with FASD: 60% of adolescents and adults diagnosed with FASD have been in trouble with the law for various crimes, ranging from shoplifting to domestic violence; 60% of adolescents and adults diagnosed with FASD have been in trouble with the law for various crimes, ranging from shoplifting to domestic violence; 53% of men and 70% of women have problems with alcohol or other drugs (>5 times the general population); 53% of men and 70% of women have problems with alcohol or other drugs (>5 times the general population); 80% of those in trouble with the law also have problems with alcohol/drug abuse. 80% of those in trouble with the law also have problems with alcohol/drug abuse. *Streissguth, a. & Kanter, J. (Eds.). (1997). ( The Challenge of Fetal Alcohol Syndrome: Overcoming Secondary Disabilities. University of Washington Press. *Streissguth, a. & Kanter, J. (Eds.). (1997). ( The Challenge of Fetal Alcohol Syndrome: Overcoming Secondary Disabilities. University of Washington Press.

32 © Children’s Research Triangle 2004 Risk factors associated with secondary disabilities: oIQ over 70 (fewer available services) oExposure to violence (72% of individuals with FASD) oThose exposed to violence are four time more likely to exhibit inappropriate sexual behavior oPerception/attitudes of authorities o“If you look normal, then you must be normal.” o“They seem bright; they should know right from wrong.”

33 © Children’s Research Triangle 2004 Protective Factors:  Early diagnosis  Eligibility for services (i.e. MR/DD)  Living in a stable home  Protection from violence

34 © Children’s Research Triangle 2004 Addressing the Legal Issues Educate judges and lawyers about FAS/FASD:  Capacity: Understanding of right from wrong is impaired  Competency: Understanding of charges and their rights  Sentencing: Extenuating circumstances  Alternative sentencing  Treatment options  Environmental support and structure

35 © Children’s Research Triangle 2004 SCREAMS – Seven Secrets to Success with FAS in the Court System © Teresa Kellerman S Structure Cues Cues Role Models Role Models Environment Environment Attitude of Others Attitude of Others Medication Medication Supervision Supervision

36 © Children’s Research Triangle 2004 S CREAMS © Teresa Kellerman STRUCTURE:  Daily routine, unchanging schedule, concrete rules and simple directions.  They would do well in prison, but not so well on probation or living independently.

37 © Children’s Research Triangle 2004 S C REAMS © Teresa Kellerman CUES:  Memory deficits result in need for constant reminders  Visual prompts, picture symbols  Schedules  Learning and re-learning, practice/rehearsal

38 © Children’s Research Triangle 2004 SC R EAMS © Teresa Kellerman ROLE-MODELS:  Mentors, coaches, positive peers  1:1 assistance  Role-playing situations with repetition to develop social competence and skills

39 © Children’s Research Triangle 2004 SCR E AMS © Teresa Kellerman ENVIRONMENT:  SI deficits intensify reactions.  Arrests feel like assaults, confined space can be suffocating, handcuffs painful  Lights, noise, activity level can be overwhelming and elicit an aggressive (self-protective) response

40 © Children’s Research Triangle 2004 SCRE A MS © Teresa Kellerman ATTITUDE OF OTHERS:   “They should know better.”   “They’re incorrigible.”   Willful/defiant   Lazy or “not working up to their potential”

41 © Children’s Research Triangle 2004 SCREA M S © Teresa Kellerman MEDICATION:  Right meds can restore limited control over mood and behavior  Wrong or inappropriate medication can exacerbate mood and behavior dysregulation

42 © Children’s Research Triangle 2004 SCREAM S © Teresa Kellerman SUPERVISION:  FAS/FASD clients involved in the criminal justice system likely will require on-going support and monitoring.

43 © Children’s Research Triangle 2004 Additional Resources: For more information about FAS/FASD and the Criminal Justice System, please check out the following website:  Which provides and overview of the issue, as well as links to relevant articles and websites.

44 © Children’s Research Triangle 2004 A Parable about Problem-Solving A person standing near a river hears a call for help and sees someone drowning. He jumps in and pulls the struggling swimmer out of the water and resuscitates him. As he finishes resuscitating the first swimmer, a second cries out. Again, he enters the water and with great effort hauls the second drowning person ashore. A third person calls out for help and he jumps to the rescue and nearly drowns in the effort, but manages to pull the third person out of the river. An admiring crowd has gathered when a fourth person calls for help and our hero walks away. “Where are you going? What about this person who is drowning?” He turns and says, “I’m tired of rescuing people from the river. I’m going upstream to find out who’s pushing them in!” Quoted from McGourty & Chasnoff (2003). Power Beyond Measure. Chicago, IL: NTI Publishing.

45 © Children’s Research Triangle 2004


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