Presentation on theme: "Debra Eisert OHSU and University of Oregon"— Presentation transcript:
1Debra Eisert OHSU and University of Oregon When Parents use Methamphetamines: Strategies for working with ChildrenDebra EisertOHSU and University of OregonWill be juggling two audiences – Helpful to have people in this room in addition to all of you out there.
2Who I am Psychologist in CDRC clinic for 27 yrs Prof at U of O on disability projects.Member of group that organized Methamphetamine workshop 2006Psychologist for BASE, a preschool program to reunite parents and children in foster careNot 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.
3ObjectivesLearn how prenatal methamphetamine exposure impacts childrenLearn how methamphetamine use by adult caretakers impacts childrenStrategies for addressing behavioral challenges.Strategies for addressing behavior depend on age, dosage, and environmental factors, Will interweave the impact on children with the strategies,
4What is MethMethamphetamine (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 hoursComes in Powder or Rock formCooked from ephedrine/pseudoephedrine plus household chemicalsPlead ignorance
5What does Meth Do?Meth causes the body to release Dopamine, a neurotransmitter, which results in pleasure or euphoriaDepletes the dopamine storesHeavy users may not be able to experience pleasure without the drugProduces a stronger, more lasting high than cocainePeople use Meth because they like what it does to their brainsSee reference list for information on brain imaging. Powerpoint by Rawson
7Who 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 classesHigh school and College students.AthletesMore men than womenMore whites than minoritiesUse is across age and social class, can be multigenerational
8Big IdeasIt 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 variablesSome symptoms are not exclusive to drug exposed childrenProject FEAT, Shah, (no date)
9Big 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 factorsInterventions depend on age, symptoms, and individual characteristics
10Different Sources of Information Research is usually behind clinical experienceExperiences of medical professionals, foster parents, child protective services, therapists, teachers are valuableLongitudinal research is very importantCan’t always separate impact of substance use and environment
11The Oregon ExperienceOregon was one of the first states to have a problem with MethIn 2004 and 2005, Oregon had 450 or more meth lab incidentsIn 2004, Oregon adopted a rule where all products containing pseudo-ephedrine must be kept behind the pharmacy counterIn 2005, the rule required ID and each sale was logged.
13The Oregon ExperienceIn 2006, a new law required that the cold medication be distributed only with a prescriptionFrom 2004 to 2011, meth lab incidents decreased from an average of 24 per month to less than one per month.
14InterpretationIn 2010, Newsweek announced that the meth epidemic in Oregon was over, due to the restrictive law. ButIn 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 statesMethamphetamine 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
15Still a problemMeth 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
16How does prenatal meth exposure impacts children Children can receive different levels of exposure, dosage and timingPrenatalBreastmilkMeth Labs and their chemicalsIndividual children may be impacted differentlyAvoid stigmatizing terms like “meth baby”Biggest impact is being raised in meth lab over time.
17Numbers of Substance Exposed Newborns National prevalence data estimates that 10-11% of all newborns are prenatally exposed to alcohol or illicit drugs. This translates toAn estimated 22,500 Oregon children ages 0-5 may have been substance exposedAn estimated half of these children were exposed to illicit drugs.In Oregon, in 2003, over 70% of foster care placements were linked to MethIn 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.
18Most Go Home from Hospital 80-95% of substance exposed infants are undetected and go home.Obstetricians may not askHospitals may not ask, test or referState Law may not require report or referralTests only detect very recent useRobert Nickel, M.D. personal communication & NCSACW, 2006
19Common Infant Symptoms any substance exposure Hypertonicity-Infant massage, passive range of motion, ( after training) Therapy if interferes with milestonesTremorMinimize stimulation, Swaddling, PT/OT?IrritabilityAvoid overstimulation, swaddling, pacifier, teach self calming by sucking on fist, rocking horizontallyPoor feeding regulationNutrition 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.
20Common 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 nipplesAfter the first month, babies often have insomnia, dysregulated sleep, jitteriness, irritabilityThese babies need swaddling, reduced stimulation, preparation for touch and holding,Foster parent college, substance exposed newborns
21How Does prenatal meth exposure impact Children? IDEAL longitudinal study1618 infants & moms, 84 with meth exposureMeth and non-meth exposed babies were also exposed to alcohol, tobacco or marijuana useMeth group 3.5 X more likely to be small for gestational age (SGA)Two times more likely to be prematureTobacco exposed group 2 X more likely to be SGA compared to controlsSmith et al, 2006Done in four cities,.1% of babies exposed to meth, 19% for alcohol, 20% for tobacco, 3% for marijuana.
22IDEAL Cont’dInfants given Neurobehavioral scale within first few days of lifeBabies had increased physiological stressHeavy use associated with decreased arousal, lethargyThese moms were recruited at delivery, which may affect memory of past useStatistically, many moms report reduced use as the pregnancy proceeds
23Toddlers and Preschoolers (any substance exposure) Speech ProblemsSLP evaluation plus interventionRead to child, language stimulationSigning after about one year of ageTemper tantrumsNormal toddler behavior or extreme?Use RedirectionCommunication strategies, behavior as communication (reframe)Positive, non-punitive responsesShah, NdShah
24Toddlers (Cont’d) Sensory Issues Desensitize to sensory issues (OT) Consider sensory treatment if the problem interferes with developmentAvoid significant triggersHelp child understand body cues and emotionsPredictable schedules
25Toddlers (cont’d) Teaching children to tolerate low level stress Children benefit from low level exposures to stress under supportive conditionsIf hungry, tired, learn that their cues will be responded to.Power of Empathy
26Case 2 1/2 year old boy seen in our clinic Physician for mom was unaware of her useRemoved from home at 18 months due to neglect, drug use, interpersonal violence. Parents were jailedSecond foster homeDiscuss value of jail time versus treatment time. Impact of neglect during this time significant. Placement in foster home with few children
27Case cont’dPrematurity, feeding issues, extreme temper tantrums, speech/language delays, distractibility, mood changesCognitive skills in average rangeSpeech/language delayDysregulated sleepAnxious about relationshipsDid not go to foster care after birth. These symptoms were present after placement in foster care.
28Interventions for Child Consistent home environment, with known caregiversReduce overstimulationDivert attention when mildly upsetTeach Self calmingConsistent interventions across caregiversImportance of relative or community care (if safe)
29Interventions (cont’d) Feeding therapySpeech/language therapy (EI)OT for sensory problemsAttachment therapyGood sleep hygiene, monitor, consider melatonin if needed
30IDEAL study ages 3 and 5166 exposed and 164 non-exposed tested at 3 and 5 yearsAt 3 and 5 years - increased emotionality and anxiety/depressionAt five years, more children had ADHDLaGasse, 2011, Pediatrics
31IDEAL cont’dAt age five years, Boys had more overall externalizing problems, more inattention, aggressive, ADHD, emotional reactivity, withdrawal and total problems than girlsChildren 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.
32TobaccoTobacco was also related to increased behavior problems, and withdrawal symptoms (e.g., easily overwhelmed).
33IDEAL Social Variables 43 children had two or more changes in primary caregiver. 59% had at least one care giver change by age 520% had low SES, 88 % had public health insurance7% exposed to domestic violence, and reported child abuse (probably an under- estimate due to caregiver report)
34M Moms in IDEAL study More likely to be single, Live in household with < $10,000 incomeTend to be younger,Have fewer, and later prenatal visitsGain more weightDon’t get prenatal care, don’t take care of themselves,. Better outcomes with prenatal care, may have weight loss and poor nutrition
35School-Aged children (any substance exposure) ADHDMedication managementBehavioral therapyReduce undesirable behaviorsHome school communicationSpecial Education ClassParent/foster parent participationShah, (no date)No specific research on using stimulants on children with meth exposure
36Strategies for Addressing School Aged Behavior Overall Intervention for Self-RegulationAdults should model their own stress management (deep breaths in through nose, out through mouth)Identify strategies for both structure and flexibilityAnticipate transitions and prepareReward children for using self calmingAvoid putting reactive children togetherIDEAL study has not extended to children in elementary school or older, but can extrapolate from other research
3712 core principles for Managing ADHD 1. Bridge or externalize time2. Use immediate consequences for positive or negative behavior3. Frequent consequences 5 positives to one negative4. More intense, but not punitive consequences
3812 core principles (cont’d) 5. Vary the rewards to prevent boredom6. ACT, don’t yack (no lectures)7. Set up reward systems8. Anticipate problems - prevent them before they occur9. Keep a disability perspective. ADHD is a neurodevelopmental disorder
3912 core principles10. Maintain a set of priorities. Ignore minor rule violations11. Don’t personalize the child’s problem. Maintain a sense of humor12. Practice forgiveness, be a mother not a martyr.(From Russell Barkley, no date)
40School aged children Social emotional regulation Secondary diagnoses TraumaTeam evaluation (educational or medical)Classroom adjustmentsPermanencyCounseling
41How does methamphetamine use by adult caretakers impact children Research on Children in Protective servicesResearch on What children can tell usImplications for foster families
42Characteristics of some parents due to meth use Irritability,paranoia,sexual arousal,days of highs and then sleep,unpredictable and dangerous.Criminal Activity,domestic violence
43Characteristics 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 appts10/34 mental health problems, psychosis, attempted suicide7/34 had referrals to child welfare, custody issuesWouldes, T., et al (2004). The New Zealand Medical Journal, vol 117.
44Substance 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 substancesRecords of 1127 children
45ResultsFor most comparisons, Children exposed to Meth were worse than the other groups onInterpersonal violenceChild EndangermentPhysical abuse andChemical exposureOut of home placementMore than 50% of children exposed to IPV
46Additional sources of trauma WeaponsViolence against siblingsStranger violenceRemoval from home and decontamination if lived in lab
47A word about TraumaChildren who experience domestic violence, parents who are irritable, paranoid, sexually aroused, may become traumatizedTrauma is defined as experiences that are outside the range of normal human life.
48TraumaWhen children are traumatized, they may experience a prolonged alarm reaction, which leads to altered neural systemsChildren can experience increased vigilance, alarm and fearThese experiences can be impacted by the proper supports
49Trauma 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 withdrawnPatterns may become ingrained
50Treating 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.
51Attachment Babies come into the world as social magnets They are ready to understand their social worldBut, babies who are born to unavailable parents have more difficulty regulating and attaching
52AttachmentBabies use the state of mind of their parent to understand their own state of mind.Process over timeBabies learn to make eye contact, communicate needs, share affect, engage in joint attention if parent is available
53ImplicationsBabies developmentally aged 7-9 months can form selective attachmentsMust have substantial, sustained contactMay have qualitatively different attachmentsProvides basis for other intimate relationshipsZeanah, et al 2012
54Implications for foster parents Child Centered modelVery 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
55Implications (cont’d) Foster parents must care for the child as an individual, psychologically as well as physicallyTransitions must be carefully managedStability must be valuedVisits with bio parents and young children are very stressful without foster parent proximity.Zeanah, et al (2011)
56Neglect is Powerful Health consequences Psychological consequences Relationship DifficultiesBehavioral consequencesSignificant impact on attachments of young children.Parents may sleep as long as three days after a binge
57What Adults can tell usInterviewed 35 adult informants with a variety of rolesInformants described children’s experiences of a rural drug culture with antisocial beliefs and practicesRural counties in the MidwestMeth use as a subcultureHaight 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 DaysChildren develop antisocial beliefs and practices throughExposure to danger, lying and stealingDrug use and violenceChildren as lookoutsChildren told not to talk about the drugs
59Individual differences Differences may be due to:Temperament, intelligence, resilienceExtended FamilyCommunity (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.
60Children’s voicesInterviewed 18 children ages 7-14 in foster care due to meth use by parentsChildren 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)
61Children’s Reports(cont’d) Observed Violence between adults,Physical abused by parents or adultsInvolvement in illegal activities, sex, drugsFearful of “being taken”, resist supports from foster family (Haight et al 2007)
62Children’s perspectives on foster families Children may resist making connections to foster familiesIf parents in prison, children face long stays in foster careHave lived semi-independently, had adult rolesHave cared for their younger sibsMay Resist rules and routines and monitoringResist foster families attempts to care for them.Haight et al, 2007Recognize divided loyalties, no negative talk about parents, discussion of addiction as illness, prepare for upset after visits,
63Implications for Foster Families Expect divided loyalties and don’t make older children chooseSupportive, empathic talk for childExpect and prepare for upset.Clear rules with flexibilityProvide normalizationIndividual/Family therapy if available.
64A Paradigm ShiftIt 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)
65Community Based Strategies Project FEAT at the U of OregonJane Squires and Robert Nickel, Directors.Improve outcomes for substance exposed newbornsTarget Systems Change in Lane County
66Project FEAT identified five points for potential intervention Pre-pregnancy awarenessPrenatal AwarenessIdentification of Child and parent at birthInfant Safety and Parent treatmentLink Systems to support child and Parent throughout development
67Lane County Activities Lane County Interagency collaborative workgroupFamily AdvocateState level collaborationOngoing evaluation
69Substance Exposed Newborn Multidisciplinary team convened at the hospital to give input into placement decisionsFamily Advocate to provide intensive intervention services to pregnant women and new moms with substance use issues
70Final Recommendations Enhance supports in school and local communityTimely involvement of Child welfareTimely access to quality mental health services that address mental health assessment, trauma, normalizationUnderstand the subculture of meth users and developmentally appropriate practice.
71Interdependence is critical Teachers may be first to note neglect, or others signs of useSchools 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