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Debra Eisert OHSU and University of Oregon

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1 Debra Eisert OHSU and University of Oregon
When Parents use Methamphetamines: Strategies for working with Children Debra Eisert OHSU and University of Oregon Will be juggling two audiences – Helpful to have people in this room in addition to all of you out there.

2 Who I am Psychologist in CDRC clinic for 27 yrs
Prof at U of O on disability projects. Member of group that organized Methamphetamine workshop 2006 Psychologist for BASE, a preschool program to reunite parents and children in foster care Not a physician, so my interest and knowledge is more in the psychological and developmental effects of methamphetamine than on the medical side but I have tried to give you resources for more medical information.

3 Objectives Learn how prenatal methamphetamine exposure impacts children Learn how methamphetamine use by adult caretakers impacts children Strategies for addressing behavioral challenges. Strategies for addressing behavior depend on age, dosage, and environmental factors, Will interweave the impact on children with the strategies,

4 What is Meth Methamphetamine (meth, ice, crystal, glass, speed, chalk, or tina) is a highly addictive, man-made drug that stimulates the pleasure section of the brain. High lasts 6-24 hours Comes in Powder or Rock form Cooked from ephedrine/pseudoephedrine plus household chemicals Plead ignorance

5 What does Meth Do? Meth causes the body to release Dopamine, a neurotransmitter, which results in pleasure or euphoria Depletes the dopamine stores Heavy users may not be able to experience pleasure without the drug Produces a stronger, more lasting high than cocaine People use Meth because they like what it does to their brains See reference list for information on brain imaging. Powerpoint by Rawson

6 Images of meth use

7 Who Uses Meth? There are more than 1.4 million meth users across the country. Was associated with blue collar white males, but meth use occurs across all social classes High school and College students. Athletes More men than women More whites than minorities Use is across age and social class, can be multigenerational

8 Big Ideas It is difficult to separate effects of meth exposure from other prenatal exposures, because parents often use more than one substance. Symptoms of prenatal exposure vary depending on timing, amount and other variables Some symptoms are not exclusive to drug exposed children Project FEAT, Shah, (no date)

9 Big Ideas (cont’d) Treatment is based on symptoms, not exposure only
Some symptoms may not be obvious until after age two years. Risk of Exposure can be Balanced by stable environment, and resilience factors Interventions depend on age, symptoms, and individual characteristics

10 Different Sources of Information
Research is usually behind clinical experience Experiences of medical professionals, foster parents, child protective services, therapists, teachers are valuable Longitudinal research is very important Can’t always separate impact of substance use and environment

11 The Oregon Experience Oregon was one of the first states to have a problem with Meth In 2004 and 2005, Oregon had 450 or more meth lab incidents In 2004, Oregon adopted a rule where all products containing pseudo-ephedrine must be kept behind the pharmacy counter In 2005, the rule required ID and each sale was logged.

12 Meth Use in the U.S.

13 The Oregon Experience In 2006, a new law required that the cold medication be distributed only with a prescription From 2004 to 2011, meth lab incidents decreased from an average of 24 per month to less than one per month.

14 Interpretation In 2010, Newsweek announced that the meth epidemic in Oregon was over, due to the restrictive law. But In 2012, the Huffington post announced that the Cascade Policy Institute had another perspective. It seems that states surrounding Oregon had a drop in admissions to treatment centers and meth labs, without the law in place in those states Methamphetamine is still available because it is brought in from Mexico. There were many complaints about the impact on health people of loss of work, medical insurance cost, of getting a prescription for cold meds

15 Still a problem Meth is still manufactured in California, often by Mexican groups, and shipped to Oregon. Some meth labs get around the law by going out of state or having a small army of buyers. As long as there are meth labs or meth use, we should be concerned about impact on children and adults

16 How does prenatal meth exposure impacts children
Children can receive different levels of exposure, dosage and timing Prenatal Breastmilk Meth Labs and their chemicals Individual children may be impacted differently Avoid stigmatizing terms like “meth baby” Biggest impact is being raised in meth lab over time.

17 Numbers of Substance Exposed Newborns
National prevalence data estimates that 10-11% of all newborns are prenatally exposed to alcohol or illicit drugs. This translates to An estimated 22,500 Oregon children ages 0-5 may have been substance exposed An estimated half of these children were exposed to illicit drugs. In Oregon, in 2003, over 70% of foster care placements were linked to Meth In thinking about these data we must acknowledge our own feelings when we think about “meth babies” “addiction is voluntary vs addiction is a disease. Those of us who have never experienced a true addiction probably don’t understand the hold it gets on the body.

18 Most Go Home from Hospital
80-95% of substance exposed infants are undetected and go home. Obstetricians may not ask Hospitals may not ask, test or refer State Law may not require report or referral Tests only detect very recent use Robert Nickel, M.D. personal communication & NCSACW, 2006

19 Common Infant Symptoms any substance exposure
Hypertonicity- Infant massage, passive range of motion, ( after training) Therapy if interferes with milestones Tremor Minimize stimulation, Swaddling, PT/OT? Irritability Avoid overstimulation, swaddling, pacifier, teach self calming by sucking on fist, rocking horizontally Poor feeding regulation Nutrition consult, bottled water between feeding (Shah, nd) Babies need optimal stimulation, but not too much. Important to teach parents to read the cues of babies.

20 Common Infant Symptoms of Meth Exposure
In the first month, babies are often lethargic, and not interested in feeding. Scheduled wakenings, foot massage to alert, specialized nipples After the first month, babies often have insomnia, dysregulated sleep, jitteriness, irritability These babies need swaddling, reduced stimulation, preparation for touch and holding, Foster parent college, substance exposed newborns

21 How Does prenatal meth exposure impact Children?
IDEAL longitudinal study 1618 infants & moms, 84 with meth exposure Meth and non-meth exposed babies were also exposed to alcohol, tobacco or marijuana use Meth group 3.5 X more likely to be small for gestational age (SGA) Two times more likely to be premature Tobacco exposed group 2 X more likely to be SGA compared to controls Smith et al, 2006 Done in four cities,.1% of babies exposed to meth, 19% for alcohol, 20% for tobacco, 3% for marijuana.

22 IDEAL Cont’d Infants given Neurobehavioral scale within first few days of life Babies had increased physiological stress Heavy use associated with decreased arousal, lethargy These moms were recruited at delivery, which may affect memory of past use Statistically, many moms report reduced use as the pregnancy proceeds

23 Toddlers and Preschoolers (any substance exposure)
Speech Problems SLP evaluation plus intervention Read to child, language stimulation Signing after about one year of age Temper tantrums Normal toddler behavior or extreme? Use Redirection Communication strategies, behavior as communication (reframe) Positive, non-punitive responses Shah, Nd Shah

24 Toddlers (Cont’d) Sensory Issues Desensitize to sensory issues (OT)
Consider sensory treatment if the problem interferes with development Avoid significant triggers Help child understand body cues and emotions Predictable schedules

25 Toddlers (cont’d) Teaching children to tolerate low level stress
Children benefit from low level exposures to stress under supportive conditions If hungry, tired, learn that their cues will be responded to. Power of Empathy

26 Case 2 1/2 year old boy seen in our clinic
Physician for mom was unaware of her use Removed from home at 18 months due to neglect, drug use, interpersonal violence. Parents were jailed Second foster home Discuss value of jail time versus treatment time. Impact of neglect during this time significant. Placement in foster home with few children

27 Case cont’d Prematurity, feeding issues, extreme temper tantrums, speech/language delays, distractibility, mood changes Cognitive skills in average range Speech/language delay Dysregulated sleep Anxious about relationships Did not go to foster care after birth. These symptoms were present after placement in foster care.

28 Interventions for Child
Consistent home environment, with known caregivers Reduce overstimulation Divert attention when mildly upset Teach Self calming Consistent interventions across caregivers Importance of relative or community care (if safe)

29 Interventions (cont’d)
Feeding therapy Speech/language therapy (EI) OT for sensory problems Attachment therapy Good sleep hygiene, monitor, consider melatonin if needed

30 IDEAL study ages 3 and 5 166 exposed and 164 non-exposed tested at 3 and 5 years At 3 and 5 years - increased emotionality and anxiety/depression At five years, more children had ADHD LaGasse, 2011, Pediatrics

31 IDEAL cont’d At age five years, Boys had more overall externalizing problems, more inattention, aggressive, ADHD, emotional reactivity, withdrawal and total problems than girls Children of younger mothers had more symptoms and poorer quality of home environment was related to more symptoms. Externalizing includes ADHD, aggressive, acting out, conduct or rule breaking.

32 Tobacco Tobacco was also related to increased behavior problems, and withdrawal symptoms (e.g., easily overwhelmed).

33 IDEAL Social Variables
43 children had two or more changes in primary caregiver. 59% had at least one care giver change by age 5 20% had low SES, 88 % had public health insurance 7% exposed to domestic violence, and reported child abuse (probably an under- estimate due to caregiver report)

34 M Moms in IDEAL study More likely to be single,
Live in household with < $10,000 income Tend to be younger, Have fewer, and later prenatal visits Gain more weight Don’t get prenatal care, don’t take care of themselves,. Better outcomes with prenatal care, may have weight loss and poor nutrition

35 School-Aged children (any substance exposure)
ADHD Medication management Behavioral therapy Reduce undesirable behaviors Home school communication Special Education Class Parent/foster parent participation Shah, (no date) No specific research on using stimulants on children with meth exposure

36 Strategies for Addressing School Aged Behavior
Overall Intervention for Self-Regulation Adults should model their own stress management (deep breaths in through nose, out through mouth) Identify strategies for both structure and flexibility Anticipate transitions and prepare Reward children for using self calming Avoid putting reactive children together IDEAL study has not extended to children in elementary school or older, but can extrapolate from other research

37 12 core principles for Managing ADHD
1. Bridge or externalize time 2. Use immediate consequences for positive or negative behavior 3. Frequent consequences 5 positives to one negative 4. More intense, but not punitive consequences

38 12 core principles (cont’d)
5. Vary the rewards to prevent boredom 6. ACT, don’t yack (no lectures) 7. Set up reward systems 8. Anticipate problems - prevent them before they occur 9. Keep a disability perspective. ADHD is a neurodevelopmental disorder

39 12 core principles 10. Maintain a set of priorities. Ignore minor rule violations 11. Don’t personalize the child’s problem. Maintain a sense of humor 12. Practice forgiveness, be a mother not a martyr. (From Russell Barkley, no date)

40 School aged children Social emotional regulation Secondary diagnoses
Trauma Team evaluation (educational or medical) Classroom adjustments Permanency Counseling

41 How does methamphetamine use by adult caretakers impact children
Research on Children in Protective services Research on What children can tell us Implications for foster families

42 Characteristics of some parents due to meth use
Irritability, paranoia, sexual arousal, days of highs and then sleep, unpredictable and dangerous. Criminal Activity, domestic violence

43 Characteristics of Moms (Any substance)
New Zealand Study of Moms referred to Alcohol and Drug Study Team ( ) 33/34 moms used multiple drugs (tobacco, alcohol, opiates) 14/34 did not keep medical appts 10/34 mental health problems, psychosis, attempted suicide 7/34 had referrals to child welfare, custody issues Wouldes, T., et al (2004). The New Zealand Medical Journal, vol 117.

44 Substance Use & Trauma Exposure
Examined children in child protective services who had lived with someone using meth, or with someone using other drugs or children whose caregivers did not use illicit substances Records of 1127 children

45 Results For most comparisons, Children exposed to Meth were worse than the other groups on Interpersonal violence Child Endangerment Physical abuse and Chemical exposure Out of home placement More than 50% of children exposed to IPV

46 Additional sources of trauma
Weapons Violence against siblings Stranger violence Removal from home and decontamination if lived in lab

47 A word about Trauma Children who experience domestic violence, parents who are irritable, paranoid, sexually aroused, may become traumatized Trauma is defined as experiences that are outside the range of normal human life.

48 Trauma When children are traumatized, they may experience a prolonged alarm reaction, which leads to altered neural systems Children can experience increased vigilance, alarm and fear These experiences can be impacted by the proper supports

49 Trauma Trauma impacts how people think, behave and feel.
Children may adopt behaviors that are functional in the home environment but not in foster care. Children are may be hyper-aroused and tune out all other information. Children may fight, scream, cry or they may appear numb, and withdrawn Patterns may become ingrained

50 Treating Trauma Experienced Therapist
Meta-analytic analysis of approaches indicated that cognitive behavioral therapy is most effective (Wethington, 2008) CBT is a combination of psychotherapy and behavioral therapy that looks at maladaptive ways of thinking, which can be modified with treatment.

51 Attachment Babies come into the world as social magnets
They are ready to understand their social world But, babies who are born to unavailable parents have more difficulty regulating and attaching

52 Attachment Babies use the state of mind of their parent to understand their own state of mind. Process over time Babies learn to make eye contact, communicate needs, share affect, engage in joint attention if parent is available

53 Implications Babies developmentally aged 7-9 months can form selective attachments Must have substantial, sustained contact May have qualitatively different attachments Provides basis for other intimate relationships Zeanah, et al 2012

54 Implications for foster parents
Child Centered model Very young children in foster care cannot maintain attachment to bio parents based on short visits. Foster parents become the primary attachment figures. Zeanah, et al, 2012

55 Implications (cont’d)
Foster parents must care for the child as an individual, psychologically as well as physically Transitions must be carefully managed Stability must be valued Visits with bio parents and young children are very stressful without foster parent proximity. Zeanah, et al (2011)

56 Neglect is Powerful Health consequences Psychological consequences
Relationship Difficulties Behavioral consequences Significant impact on attachments of young children. Parents may sleep as long as three days after a binge

57 What Adults can tell us Interviewed 35 adult informants with a variety of roles Informants described children’s experiences of a rural drug culture with antisocial beliefs and practices Rural counties in the Midwest Meth use as a subculture Haight et al (2005), In these bleak days . . . Many community members view meth as a voluntary activity and a moral failure rather than an addiction that is very powerful

58 “In these Bleak Days Children develop antisocial beliefs and practices through Exposure to danger, lying and stealing Drug use and violence Children as lookouts Children told not to talk about the drugs

59 Individual differences
Differences may be due to: Temperament, intelligence, resilience Extended Family Community (e.g., school practices) Some parents who use, do understand the impact on their children and try to protect them, sometimes by finding other adults to meet the children’s needs. Interpretation is important “parents are ill, things will get better, not child’s fault”, positive relationships with another adult.

60 Children’s voices Interviewed 18 children ages 7-14 in foster care due to meth use by parents Children are frightened and sad about their parents use and about involvement of law enforcement. May describe parents as mean, hyper, fighting, psychotic. May follow parent directions to not talk, to deny meth use by parents. They may believe parents were “set up.” Haight et al, (2007)

61 Children’s Reports(cont’d)
Observed Violence between adults, Physical abused by parents or adults Involvement in illegal activities, sex, drugs Fearful of “being taken”, resist supports from foster family (Haight et al 2007)

62 Children’s perspectives on foster families
Children may resist making connections to foster families If parents in prison, children face long stays in foster care Have lived semi-independently, had adult roles Have cared for their younger sibs May Resist rules and routines and monitoring Resist foster families attempts to care for them. Haight et al, 2007 Recognize divided loyalties, no negative talk about parents, discussion of addiction as illness, prepare for upset after visits,

63 Implications for Foster Families
Expect divided loyalties and don’t make older children choose Supportive, empathic talk for child Expect and prepare for upset. Clear rules with flexibility Provide normalization Individual/Family therapy if available.

64 A Paradigm Shift It is time to view child abuse and parent chemical dependency as a multi-generational legacy family that can only be healed by defining “the client” as “the family” Susie Dey, Director of Child and Family Services at Willamette Family Treatment, 40 years experience in child welfare.(Project FEAT)

65 Community Based Strategies
Project FEAT at the U of Oregon Jane Squires and Robert Nickel, Directors. Improve outcomes for substance exposed newborns Target Systems Change in Lane County

66 Project FEAT identified five points for potential intervention
Pre-pregnancy awareness Prenatal Awareness Identification of Child and parent at birth Infant Safety and Parent treatment Link Systems to support child and Parent throughout development

67 Lane County Activities
Lane County Interagency collaborative workgroup Family Advocate State level collaboration Ongoing evaluation

68 Established workgroups
Prenatal screening Hospital Policy Substance exposed newborn team Postnatal supports Project FEAT

69 Substance Exposed Newborn
Multidisciplinary team convened at the hospital to give input into placement decisions Family Advocate to provide intensive intervention services to pregnant women and new moms with substance use issues

70 Final Recommendations
Enhance supports in school and local community Timely involvement of Child welfare Timely access to quality mental health services that address mental health assessment, trauma, normalization Understand the subculture of meth users and developmentally appropriate practice.

71 Interdependence is critical
Teachers may be first to note neglect, or others signs of use Schools provide clothing, food & toiletries. Schools as normalizing, safe places. Communication between child welfare, police, county law enforcement. (Haight et al 2005) Teachers may also be threatened if they report to child welfare, because in rural areas, parents may figure it out. Communities fear threats to the ground water, explosions of meth labs

72 Questions?

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