Institute for Health and Recovery

Institute for Health and Recovery
Treatment Approaches for Children of Parents with Co-Occurring Substance Use and Mental Health Disorders and Histories of Violence/Trauma Norma Finkelstein, Ph.D. Karen Gould, LICSW Institute for Health and Recovery Strengthening Connections Conference - AIA September 11, 2012 Austin, TX Institute for Health and Recovery

Key Facts about Child Traumatic Stress
Institute for Health and Recovery 2

Definition: Childhood Trauma
The mental result of one sudden external blow or a series of blows, rendering the young child temporarily helpless and breaking past ordinary coping and defensive operations. Source: Lenore Terr, M.D. , 1991 Institute for Health and Recovery

Key Facts: Child Traumatic Stress
Child Traumatic Stress is common: More than 25% of American youth experience a serious traumatic event by the age of 16, and many children suffer multiple & repeated traumas. Common sources of trauma include abuse and neglect; experiencing or witnessing violence in neighborhoods, schools, and homes; serious accidental injury; disasters and terrorism; and treatment for life-threatening illness. Young children are exposed to traumatic stressors at rates similar to those of older children. In one study of children aged 2–5, more than half (52.5%) had experienced a severe stressor in their lifetime. Institute for Health and Recovery 4

Key Facts: Child Traumatic Stress
Child Traumatic Stress can be identified: Signs of traumatic stress include fear, anger, withdrawal, trouble concentrating, nightmares and digestive problems. Children’s distress may not be obvious or visible; by talking with them you might find out what is going on. Children may feel ashamed, guilty, betrayed or weak and may seem numb as they try to avoid their own feelings. Prior trauma, past mental health problems, or a familial history of such problems may increase a child's risk. Serious, ongoing traumatic stress reactions are hallmarks of Post-traumatic Stress Disorder (PTSD). Institute for Health and Recovery 5

Possible Impacts of Trauma/CODs on Children
Sleep Disturbance-nightmares, trouble waking and falling asleep Separation anxiety and clinginess Aggressive behavior and angry feelings High activity level, emotional numbing Constant worry about possible danger Forgetting how to do things that they have mastered Withdrawal form friends and activities Difficulty in concentrating and then the reference Source: Child Witness to Violence Project, Boston Medical Center, Boston, MA from the Child Witness to Violence Project, Boston Medical Center, Boston, MA Institute for Health and Recovery Institute for Health & Recovery - Karen Gould - 2/3/2006

Coping Strategies Children exposed to traumatic events may develop trauma- related cognitions & coping strategies: Inappropriate self-blame Global sense of impending danger Operating under chronic ongoing distress Ongoing or intermittent functional impairment Institute for Health and Recovery

Biology: Trauma & the Developing Brain
Trauma may affect the physical development of the brain The brain is on a “use it or lose it” plan The brain drives the body’s “fight or flight” stress response The biology of resilience Institute for Health and Recovery

Three Domains Impacted by Childhood Trauma
Affect Identification Awareness of/connection to own emotional experience Capacity to read cues in others Affect Modulation Capacity to self-soothe, calm Lack of connection among emotional states Affect Expression Capacity to safely express emotions Capacity to communicate emotional experience to others Source: Margaret Blaustein, 2006 Institute for Health and Recovery

Attachment The emotional connection children form with their parents or primary caregivers Healthy attachment depends heavily on parent or caregiver behavior; it’s important that the process begin as soon as possible Early positive attachments help children to develop & maintain health relationships throughout their lives Babies with a healthy, secure attachment understand that the parent or caregiver is a source of comfort & a solid base from which to explore and play Institute for Health and Recovery

Attachment Provides a sense of security Regulation of affect & arousal Expression of feelings & communication A base for exploration Institute for Health and Recovery

Young Children Early development across 5 areas: closely linked (adaptive, cognitive, communication, motor, social-emotional) Attachment as foundation of developing brain Young children’s brains: resilient/responsive Let’s talk about young children and their early development. We know now that young children’s brains respond in significant ways to the environment around them , especially to their primary caregiver. So, when that caregiver is unable to provide a consistent response, young children’s brains can be affected. Institute for Health and Recovery

What is my baby trying to tell me?
The attachment process boils down to detective work Institute for Health and Recovery

Family-Centered Interventions
Benefit both children & parents Broaden focus from nuclear family to network of supports – relatives, friends, etc. Are strengths-based and focus on resiliency building Are aimed at relationship-strengthening Value families having a meaningful voice & choice Are inclusive, flexible, responsive & culturally relevant Institute for Health and Recovery

Working at the Interface of Substance Use Recovery & Early Parenting
Project BRIGHT: Building Resilience through Intervention – Growing Healthier Together Working at the Interface of Substance Use Recovery & Early Parenting Institute for Health and Recovery

Project BRIGHT Collaborators
Institute for Health and Recovery Jewish Family & Children’s Service, Center for Early Relationship Support Boston University School of Social Work Boston Medical Center, Child Witness to Violence Project Institute for Health and Recovery

Project BRIGHT Designed to address traumatic stress in parents in recovery from substance use and co-occurring disorders & their children, birth-5 Parents & children are in residence at one of the 8 Family Residential Treatment (FRT) programs across Massachusetts Will serve 80 children & their families over 3 years of grant Institute for Health and Recovery

Project BRIGHT Goals Address symptoms of complex trauma and build resilience in young children in FRTs Enhance the quality of parent-child relationships Build capacity of FRTs to address children’s trauma needs Pilot adaptation of Child Parent Psychotherapy as model for this population Institute for Health and Recovery

Family Residential Treatment
Serve approx. 247 families, with 259 children, per year Funded & licensed by Bureau of Substance Abuse Services 8 programs with families; each with own culture & approach 80% of families have children under 5 One-third are reunifying with child on site Families stay 6-12 months Goals are program completion and housing stability Institute for Health and Recovery

Project BRIGHT in the FRT’s
For FRT realities: Shorter term intervention Include pregnant women and mothers with infants For challenges/needs of population in early recovery: Explicit focus on building Reflective Function (RF) Central role of emotion regulation Attunement to issues of separation, loss, and transitions in relationships and in the milieu Institute for Health and Recovery

Who We Serve Caveat: served fathers at 1 of the 8 FRT’s Have seen 76 dyads Clinical experience of women & children: Few capacities for emotion regulation; substance use has been response to intolerable affects Most parenting sober for first time Extensive maternal trauma histories Relationships with children characterized by separations & losses Institute for Health and Recovery

Child-Parent Psychotherapy (CPP)
Developed by Alicia Lieberman, Patricia Van Horn & colleagues at UCSF Relationship-based dyadic intervention Manualized – Don’t Hit My Mommy, published by Zero to Three press Home- or office-based Bi-lingual capacity Groves, Noroña, Child to Witness Violence Project 12/9/09 Institute for Health and Recovery

Child-Parent Psychotherapy (CPP)
Relationship-based treatment for children birth-6 who have been exposed to family violence Focuses on the trauma-affected attachment of parents & young children, toward goal of reducing traumatic stress & behavioral symptoms Focuses on improving the parent-child relationship Institute for Health and Recovery

Focus of CPP Caregiver-child interactions The relationship is the client Emotional experience of both caregiver & child are valued Targets the system of jointly constructed meanings (often inaccurate and/or problematic) in the caregiver-child relationship Groves, et al. Institute for Health and Recovery

BRIGHT Modifications/ Adaptations to CPP
Length of treatment shortened to 6-8 months Aimed at bringing philosophy & ideas of CPP to the FRT staff & milieu environment Include women who are pregnant—anticipate their children’s needs related to danger & safety Focus on Reflective Function—the capacity to understand child’s inner world & the link between behavior and intentions, feelings & needs For women in recovery from SUD/COD, treatment that targets maternal reflective capacity has been shown to be effective Suchman, Nancy, et al., (2008) The Mothers and Toddlers Program, Psychoanalytic Psychology, 25, Institute for Health and Recovery

Core Concepts in Project BRIGHT
Containing/regulating feeling states Recognizing own and child’s feelings Clinician as calming presence Strategies for reducing distress Building parental reflective function Wondering about child’s perspective Making sense of behavior Reflective function growth “I’m so much more aware of this baby because I was high when my older kids were little.” “I would never think you could ask those questions about your child.” Institute for Health and Recovery

Evaluation of Project BRIGHT: An Update on Findings
Ruth Paris, Ph.D. Gina Mittal, MSW Lisa Schottenfeld, MSW, MPH Institute for Health and Recovery

Measures Traumatic Experiences Screening Inventory (TESI)
Child’s exposure to traumatic events Traumatic Symptoms Checklist – Young Child (TSCYC) Child’s symptoms of traumatic stress Adult-Adolescent Parenting Inventory (AAPI) Parenting practices in domains including empathic practices, role reversal, appropriate expectations, and use of physical discipline Reflective Functioning Questionnaire (PRFQ) Parent’s ability and inclination to engage in reflective functioning Brief Symptom Inventory (BSI) Parent’s symptoms of psychopathology: scales for depression, anxiety, traumatic stress, psychotic thinking, somatization Life Stressors Checklist – Revised (LSC-R) Parent’s exposure to traumatic life events with an emphasis on events germane to family conflict Client satisfaction survey and Qualitative interview Parent’s perceptions of and satisfaction with the intervention and their clinician Trauma-Informed Practices Survey Staff member’s knowledge of and self-perceived ability to provide trauma-informed care Staff interviews and/or focus groups Staff members’ perceptions of and satisfaction with the intervention and its effects on the FRT as a whole PIR-GAS/RPCL (DC0-3R) Relationship Measures: assessment of overall quality of parent-child relationship and specific problematic aspects

Methods & Demographics
Design: Baseline treatment: n = 76 Evaluation Tools: Self-report questionnaires Observer-rated instrument Administrative data from the Bureau of Substance Abuse Services, MA Department of Public Health Average age of parents: 28.5 years Average age of children: 1.6 years 75% white, 21% Latino, % African American 38% did not receive high school diploma or GED 97% unemployed Substance of choice tends to be heroin or other opiates, cocaine, or crack Average number of sessions: 12 Institute for Health and Recovery

Trauma histories (LSC-R and TESI) *women only
Parents (LSC-R): Parents participating in BRIGHT report exposure to a mean of 13 traumatic events Common exposures include: physical abuse; emotional abuse or neglect; family members’ substance abuse; abortion, stillbirth, or miscarriage; sudden death of someone close Children (TESI): Parents participating in BRIGHT report that children have been exposed to a mean of 3 traumatic events Common exposures include separation from parent or other caregiver; seeing or hearing family members fighting or threatening to harm to each other; seeing or knowing family member arrested or incarcerated; serious illness or medical procedures Institute for Health and Recovery

Research Question Is participation in Project BRIGHT associated with changes in participants’ psychological health and parenting? Institute for Health and Recovery

Parents’ Psychological Distress at Baseline & Post-Treatment (BSI)
Scale BRIGHT treatment mean at baseline (SD), n=75 BRIGHT treatment mean at post (SD), n=59 Community Sample mean Global 1.03** (.61) .77*** (.58) .30 ***p≤.001 Participants in BRIGHT suffer worse psychological distress (depression, anxiety, hostility, paranoia) than those in the community sample BSI scores declined significantly, indicating less psychological distress after receiving Project BRIGHT Institute for Health and Recovery

Likelihood of Child Maltreatment at Baseline & Post-Treatment (AAPI)
Compared to a community sample: Parents participating in BRIGHT show tendencies to be at higher risk for lack of empathy towards their children and restricting their children’s power and independence Statistical trends demonstrate that the mothers who are less psychologically distressed after Project BRIGHT treatment are less likely to hold inappropriate expectations for their children and less likely to endorse corporal punishment. Institute for Health and Recovery

Parental Reflective Functioning at Baseline & Post-Treatment (PRFQ)
BRIGHT treatment mean at baseline (SD), n=76 BRIGHT treatment mean at post (SD), n=59 Expert rating of standard for highly mentalizing mothers High Scale 5.49*** (.61) 5.55*** (.56) 6.29 Low Scale 2.17*** (.65) 2.15*** (.70) 1.43 Significance as compared to expert rating ***p≤.001 At baseline and post, mothers participating in Project BRIGHT are significantly different from expert ratings of highly mentalizing mothers Changes on the high and low PRFQ scales are not statistically significant, however, the change that was measured is going in the desired direction Institute for Health and Recovery

Parent-Infant Relationship Global Assessment Scale (PIR-GAS)
The PIR-GAS assesses relationship between parent and child. Secure, insecure, disordered attachments, etc., tend to be powerful predictors of later functioning. The majority of mothers in the BRIGHT treatment group have relationships with their children that can be classified as “disordered,” “disturbed,” “distressed,” or “significantly perturbed.” Institute for Health and Recovery

Improved Parent-Child Relationship in BRIGHT Treatment Group (PIR-GAS)
Mean at baseline (SD) Mean at post (SD) Mean difference (SD) Sig (2-tailed) Treatment Group (n=58) 50.26 (13.91) 55.45 (14.29) 5.19*** (10.00) .000 ***p≤.001 Institute for Health and Recovery

Pathways to Better Parenting
Statistical trends show that less psychological distress after BRIGHT (BSI) is linked to better Reflective Functioning (PRFQ) and better relationships (PIR-GAS) Mothers who are less psychologically distressed after treatment are significantly more likely to have better levels of reflective function. Less psychologically distressed mothers are significantly more likely to have better relationships with their children (higher PIR-GAS scores). Better reflective functioning after BRIGHT (PRFQ) is significantly associated with improved parent-child relationships in BRIGHT treatment group (PIRGAS) Institute for Health and Recovery

Summary of Findings Project BRIGHT participants report significantly less psychological distress after treatment. Those who are lowest on psychological distress after participating in BRIGHT are less likely to hold inappropriate expectations for their children or to endorse corporal punishment and report better levels of RF. In addition, Project BRIGHT clinicians note improvements in mother-child relationships after treatment (PIR-GAS). Those who do experience improvements in these relationships are also likely to be more reflective about their children. Institute for Health and Recovery

Client Interviews 41 client interviews conducted at 8 FRTs Select themes from client interviews Reflective Functioning Differences in parenting after BRIGHT Institute for Health and Recovery

Reflective Functioning: Sub-Themes
Self-reflection Reflecting on how own childhood affects current parenting Reflective parenting Institute for Health and Recovery

Reflecting on How Own Childhood Affects Current Parenting
“I didn’t have anybody, like my father was a crackhead and me and my mom used to not get along and I was a daddy’s girl so I was always sticking with daddy, you know, in and out of crack houses and at ten years old I learned how to hit a vein… I was shooting my father up and I was shooting all his friends up and it’s just kinda like, I never had that childhood where you like sit down and color. And I want that for my kids. It’s so important to me to like, sit down and color with them.” Institute for Health and Recovery

Reflective Parenting “Putting myself into their shoes and figuring out, you know, what they thought about it and how they felt. Everything from them first moving their heads to, you know, emotions. How frustrating it is that they can’t move their heads, and they can’t tell me what they want. You know, she [clinician] made me realize that babies have it tough.” Institute for Health and Recovery

Reflective Parenting “I also realized like when my patience drops, and I’m at that breaking point and I’m frustrated… he reads off of my feelings and he gets even more frustrated so as long as I take myself out of the room, like and I come back calm, things are a lot calmer and easier to deal with, and we’ll start from the beginning.” Institute for Health and Recovery

Reflective Parenting “Even being in a house, there’s women all the time that… but as I even get into an argument with one, holding my daughter… how do I think they’re feeling listening to their mom tighten up and yell and scream at this other girl? Well, how are they feeling? Because they’re not enjoying it. And they’re getting scared. And I’ll have to walk away, and I’ll think about it.” Institute for Health and Recovery

Differences in Parenting After BRIGHT: Sub-Themes
Closer to child Pay closer attention to child’s needs Better understanding of child More consistent with child Engage & communicate with child Institute for Health and Recovery

Closer to Child “I kinda feel the changes in me and in my son, I don’t know, just feel more closer to him. Before I didn’t feel that close, cause I don’t know I was like, ‘oh my god he’s a pain in the butt, oh my god he doesn’t want to sleep in his own bed,’ and now it’s like he doesn’t want to sleep in his own bed because he loves me, he wants to be close to me. So before it was all about complaining, and like now it’s about being grateful.” Institute for Health and Recovery

Engage with Child “…’cause I used to think that being a parent… being a mother was just being the mother, just feed ’em, change ’em, and that’s it, you know? I… I did not do any bonding with none of my other kids. I don’t think I even read ’em a book once. The playing… that was a low too... with this, with this baby, I just had changed a lot, my way of thinking.” Institute for Health and Recovery

Communicate with Child
“So even little things like getting down on her level… I try to stop and explain to her… I’ll like, kneel down and I’ll say ‘mommy will be right back and clean the plates ’cause we’re all finished with dinner’… as simple as I can run it through with her. I’m communicating with her, I’m not just leaving her there to scream and fend for herself.” Institute for Health and Recovery

Summary of Findings: Client Interviews
With new knowledge about their children, and after learning more about themselves and their past experiences, participants perceived that they were better able to engage in reflective parenting Participants were able to share the ways in which they felt that they had changed as parents as well as how their relationships with their children changed after working with the Project BRIGHT clinicians Institute for Health and Recovery

Clinical Experiences Signs of success: Clients request to be referred to BRIGHT Parents welcome focus on relationship with their child Parents understand concepts of BRIGHT High rates of enrollment & retention Clients express satisfaction & learning Institute for Health and Recovery

Lessons Learned Share BRIGHT concepts in user- friendly language “You’re using BRIGHT principles when you…” Focus on “small moments with big meanings” (transitions, good-byes) Encourage a milieu that is child- friendly Child’s first day; best practices for reunification Saying good-bye; planned & unplanned endings Opportunities in daily routines: meals, baths Institute for Health and Recovery

Lessons Learned Participation in staff meetings & case conferences: Build collaborative relationships with staff Model/encourage a curious, reflective stance Highlight opportunities for thinking about experience of parent, child & relationship Share Project BRIGHT principles as frame Institute for Health and Recovery

Challenges of Implementation
How to hold a clinical mind in a non-clinical environment? Environment often unpredictable & in crisis Focus on recovery & house rules can be in conflict with relational treatment approach Guest status at FRTs; not decision-making Institute for Health and Recovery

Challenges of Implementation
Milieu realities impact treatment: Daily routines & demands on women and children Lack of consistent treatment space Unplanned leavings Group living both supports & stresses coping capacities Institute for Health and Recovery

…just saying… Recovery staff: “It’s so good to hear when anyone talks about the importance of relationships.” Mother: “I’ve learned how my relationship with my daughter is a template for her relationships with other people.” Mother: “The twins have been through a real lot. Pretty much, I’ve never been a sober mom, ever.” Mother: “I think they taught me really how to love them.” Mother: “A lot of things that we talked about, like, really did make sense because a lot of things I didn’t understand because I had never parented while I was clean.” Institute for Health and Recovery

SAMHSA’s Women, Co-Occurring Disorders & Violence Study (WCDVS) Children’s Subset Study Institute for Health and Recovery

Target Population Children, aged 5-10, of women enrolled in the WCDVS Children had at least weekly personal contact with mother/caregiver enrolled in WCDVS Only one child per family enrolled in the study Institute for Health and Recovery

WCDVS Children’s Subset Study Overview
4 of the 9 WCDVS women’s study sites chosen to participate Development and implementation of standardized, strengths-based interventions Outcome evaluation of children enrolled Interviews conducted with mothers/caregivers Institute for Health and Recovery

WCDVS Children’s Study Sites
ALLIES Project PROTOTYPES W.E.L.L. Project New Directions for Families Institute for Health and Recovery Institute for Health & Recovery - Karen Gould - 2/3/2006

Children’s Subset Study Primary Goals
For children of mothers with co-occurring mental health & substance use disorders & histories of violence: Generate empirical knowledge about the effectiveness of trauma-informed, age-specific intervention models Identify models of care that will prevent or reduce intergenerational perpetuation of violence Institute for Health and Recovery

Core Intervention Components
Clinical assessment – mother & child Resource/service coordination & advocacy Skills-/resiliency- building group Group Work with Children of Battered Women: A Practitioner’s Manual, Peled and Davis, Sage Publications, 1995 Institute for Health and Recovery

Children’s Subset Study: Primary Research Question
Are trauma-informed, age-specific interventions for children more effective than usual care conditions in leading to increases in safety, self-care, positive interpersonal relationships and self-identity? Institute for Health and Recovery Institute for Health & Recovery - Karen Gould - 2/3/2006

Sample Overview N=253 at Baseline N=209 at 6 Months (82.6%) N=217 at 12 Months (85.8% Retention) N=195 (77.1%) Received Baseline, 6 Month & 12 Month Interviews Intervention & Comparison Groups Statistically Equivalent on Demographic Characteristics Across Follow-Ups Institute for Health and Recovery Institute for Health & Recovery - Karen Gould - 2/3/2006

Major Group Goals To “break the secret” of abuse in their families To learn to protect themselves To experience the group as a positive & safe environment To strengthen their self-esteem Institute for Health and Recovery

Children’s Group Key Session Elements
Message of the week Example: “Abuse & violence are not okay” Check-in Feeling of the day Example: “Sad” Activities & process Personal affirmation “Pass the squeeze” Snack Reward/reinforcement Institute for Health and Recovery

Children’s Group Orientation – with mothers & children Week 1: Getting to know each other/message: it’s okay to feel & express feelings* Week 2: What is abuse? “Abuse is not okay and it’s not my fault.” Week 3: Anger “It’s okay to feel and express feelings.” Week 4: It’s not always happy at my house Week 5: Sharing personal experience with violence “I am not the only one.” *Adapted from: Groupwork With Children of Battered Women, Peled & Davis, Sage Publications, 1995 Institute for Health and Recovery

Children’s Group (Cont.)
Week 6: Touch - “My body is private and I have a right to protect it.” Week 7: Assertiveness/Conflict Resolution - “I can be strong without being abusive.” Week 8: Safety (Protective) Planning - “I have the right to be safe.” Week 9: Review and good-bye - “It is okay to have fun.” *Adapted from: Groupwork With Children of Battered Women, Peled & Davis, Sage Publications, 1995 Institute for Health and Recovery

Characteristics of Children
Average age – 7.28 years In legal custody of mother – 74.3% Involved in child welfare system – 39% Experiencing emotional or behavioral problems – 67.5 % Parent convicted of a crime – 79.8% Parent treated for substance abuse – 98% Institute for Health and Recovery

Black/African American
Race/Ethnicity White/Caucasian 36% Hispanic/Latina 26% Asian/ Pacific Islander 1% Native American 1% Black/African American 36%

Prevalence of Victimization
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WELL Child Outcomes Primary Outcome Variable Behavioral & Emotional Rating Scale (BERS) Strength Quotient (Epstein & Skaima, 1998) Secondary Outcome Variables BERS Subscales Tools for improving relationships Family involvement Capacity for closeness Positive self-identity Measure of Safety Knowledge Child knows what to do to keep self safe when feels threatened by another person (4 Point Scale) Institute for Health and Recovery

Short-Term Effects (6 months post baseline)
Primary Outcomes Involvement in intervention lead to comparable, but not better, improvement than treatment as usual Mother’s outcomes affected children’s outcomes Children in comparison whose mothers had negative outcomes did worse Children whose mothers had positive outcomes did well in both conditions Institute for Health and Recovery

Short-Term Effects (6 months post baseline)
Secondary Outcomes Enrollment in the standardized intervention appears to lead to improvements in positive interpersonal relationships, knowledge about safety & positive self-identity Institute for Health and Recovery

Long-Term Effects (12 months post baseline)
Primary Outcomes Involvement in intervention leads to sustained improvement compared to children in comparison group Mothers’ outcomes do not play role in sustaining children’s positive outcomes Younger children show more improvement regardless of condition Children in intervention group performed consistently better across all age groups Institute for Health and Recovery

Long-Term Effects (12 months post baseline)
Secondary Outcomes Intervention plays role in sustaining improvements in positive interpersonal relationships, knowledge regarding safety & positive self-identity Institute for Health and Recovery

Summary of Results In short-term (6 months), mother’s overall treatment outcome plays stronger role in children’s outcomes than involvement in the intervention In long-term (12 months), participation in intervention leads to sustained positive improvement regardless of mother’s outcome, with younger children showing a greater degree of positive change than older children Institute for Health and Recovery

Lessons Learned Children can be the motivator for women to seek treatment Treatment of the woman offers an opportunity to provide services to the children Traumatic childhood experiences influence the ability to parent Victimization if children triggers memories in the parent Motherhood is both a major source of identity and self-worth, and a source of shame and guilt Institute for Health and Recovery

Lessons Learned Extreme guilt & shame must be addressed in order to build healthy parenting relationships The support of a parent who has experienced similar challenges is critical to overcome fear and guilt Must have well developed working relationships with child welfare agencies System-related issues of confidentiality & privacy must be addressed in order to promote healthy boundaries Institute for Health and Recovery

Children Need… Safety Developmentally appropriate information about addiction, mental illness, violence and recovery To express their feelings about their experiences in a safe place Emotional skill-building Time to re-establish trust in the parent-child relationship Screening/assessment for mental health/trauma and recovery service referral Institute for Health and Recovery

“Don’t Take the Bait” Guidelines for self-care when working with children who act out their pain Don’t take the bait: be careful of projective identification Retreat in fantasy: early and often Use your words, not your behavior Don’t take this work too seriously Give to them in ways that are meaningful to them Know your limits: “something has to be something” Learn to measure success differently Look for humor: it is everywhere Keep sanctuary Source: Lynn Sanford, LICSW Institute for Health and Recovery

Rules to Practice By Children are remarkably resilient It’s never too early or too late to intervene There must be a commitment from us – the professionals – to keep children, their voices, and their stories at the core of our work We need to understand the full emotional impact of violence on children We need to respond to the crisis of violence by re-establishing safety and stability Work from a position of constant compassion – easy to say, not easy to do Care for your colleagues and care for yourself Institute for Health and Recovery

Resources and References
Children of Substance Abusers Resource List, v.pdf National Association for Children of Alcoholics TIE Women’s Forum, Children & Families page The National Center on Substance Abuse and Child Welfare Adverse Childhood Experiences Study website National Abandoned Infants Assistance Center Fetal Alcohol Spectrum Disorders Center for Excellence Institute for Health and Recovery

Selected Parenting Program Resources
The Nurturing Program for Families in Substance Abuse Treatment and Recovery Celebrating Families Incredible Years Strengthening Families Institute for Health and Recovery

Resources ARC: Attachment Regulation and Competency National Child Traumatic Stress Network Child-Parent Psychotherapy (CPP) “Don’t Hit My Mommy” developed by Alicia Lieberman and Patricia Van Horn Adult Children of Alcoholics" by Janet G. Woititz, Ed.D. Understanding Addiction and Recovery Through a Child's Eyes" by Jerry Moe Institute for Health and Recovery

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