Transcript SA-Armand-9-13

Child & Family
Investigator
Colorado
Armand Lebovits, LCSW, CAC III
[email protected]
Substance Use Disorders
Substance Abuse
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CJD 04-08 Standard 13
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CFIs no longer “routinely” conduct testing
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Make recommendations to court for testing and/or
evaluation if appropriate
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Done by CFI only if sole issue of appointment, and if
qualified
Substance Abuse
An enormous problem
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More than one in 10 in US live with dependent or
abusing parents
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Profound effects on the children
Effects on Parenting
The effects of Substance Abuse on Parenting
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Parent unavailable to child
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Parent disappears
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Parent wastes the resources of the family
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Unstable housing, community and schools
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Criminal activity, child endangerment
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Child more likely to abuse
What the Child experiences
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Broken promises
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Inconsistency and unpredictability
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Shame and humiliation
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Tension and fear
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Paralyzing guilt and an unwarranted sense of
responsibility
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Anger and hurt
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Loneliness and isolation
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Lying as a way of life
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Feeling Responsible and obligated
CHARACTERISTICS OF AN ADDICTION
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DENIAL
IMPULSIVITY-SENSE OF IMMEDIACY
COMPULSION TO USE
LOSS OF CONTROL
TOLERANCE
WITHDRAWAL OF USE (OR
BEHAVIOR) LEADS TO DISCOMFORT
PROGRESSION OVER TIME
UNDERSTANDING SUBSTANCE
USE AND DISORDERS:
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DSM V DIAGNOSTIC CRITERIA (Slides 21-27)
CONTINUUM OF USE MODEL
-NO USE/NON-PROBLEM,
SOCIAL/RECREATIONAL USE, MISUSE,
BINGE USE, ABUSE, DEPENDENCE
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CO-OCCURRING M.H. DISORDERS AND
S.A. DISORDERS
DEFENSE MECHANISMS
IMPACT ON COGNITIVE, PSYCH. & SOCIAL
SYSTEMS
CONTINUUM OF USE MODEL
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Social/Recreational
Heavy Drinking/Problem Drinker
Misuse
Sustained vs. Periodic Use
Abuse (Heavy Episodic Binging-5+ drinks)
Dependence (Psychological/Physiological)
Addiction/Addictive Behaviors
ADDICTION AS AN ATTACHMENT
DISORDER
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A DISORDER IN SELF-REGULATION
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DYSFUNCTIONAL ATTACHMENT STYLES
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PADS VS. DAPS (PEOPLE ARE DRUG SUBSTITUTES
vs. DRUGS ARE PEOPLE SUBSTITUTES)
THOSE DEPENDENT ON ADDICTIVE SUBSTANCES
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CANNOT REGULATE THEIR EMOTIONS, HAVE PROBLEMS
WITH SELF-CARE, SELF-ESTEEM AND INTERPERSONAL
RELATIONSHIPS
THE POPULATION
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PRE/POST DIVORCE – USUALLY HIGH CONFLICT
OVERREACTION AROUND SUBSTANCE ABUSE/
DEPENDENCE
TENDENCY FOR ONE OR BOTH PARTIES TO
EMBELLISH OR MINIMIZE USE OF SELF/OTHER
OFTEN DUAL-DIAGNOSIS ISSUES, TRAUMA…
THERE MAY BE CRIMINAL AND CIVIL LEGAL
ISSUES AT STAKE
GENERALLY, THIS IS A RESISTIVE POPULATION
GOALS OF A SUBSTANCE USE
EVALUATION
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To understand the role that a substance plays in a
person’s life/level of involvement with the
substance
To determine how the substance use impacts the
person’s functioning
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Cognitive: executive functioning, judgment, decisionmaking, tracking/monitoring, problem solving,
memory,
Psychological: mood, feelings, emotional regulation
Social/Legal/Occupational
Medical/Physical
To offer recommendations that can be
implemented into a parenting plan
To provide a piece of the puzzle for a larger
evaluation
THE TRUTH IS RARELY PURE
AND NEVER SIMPLE
OSCAR WILDE
WHAT GETS US INTO TROUBLE
IS NOT WHAT WE DON’T KNOW,
IT’S WHAT WE KNOW FOR SURE
THAT JUST AINT SO!
MARK TWAIN
KEY CONSIDERATIONS
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Is the concern a current problem
(within the past 12 months)?
How much of a factor is the stress of
the divorce?
Has use occurred during parenting
time/Does use impact parenting?
Documented history vs. “He said, She
said”?
KEY CONSIDERATIONS
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Past substance use and mental
health treatment history/records?
Is concern based on single or
multiple episodes?
Meaning of allegations in the context
of the divorce dynamics.
Are there concerns about the
credibility of the
accuser/allegations?
IMPLICATIONS FOR PARENTING PLANS
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Overall concern is keeping children safe
Do there need to be restrictions on parenting
time?
Do the parents need treatment?
Do children and/or other family members need
treatment or support?
IMPLICATIONS FOR PARENTING PLANS
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Overall concern is keeping children safe
Do there need to be restrictions on parenting
time?
Do the parents need treatment?
Do children and/or other family members need
treatment or support?
IMPLICATIONS FOR PARENTING PLANS
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Is limited substance use OK?
What defines relapse/How to
respond?
Is monitoring necessary?
IMPLICATIONS FOR PARENTING
PLANS:
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MONITORING STRATEGIES
What Tests to Use:
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Breath/Saliva testing
Urine testing
Blood testing
Hair testing
Transdermal (Sweat)
Frequency of Testing: Random or Fixed
Duration of Testing
Response to Missed, Dilute or Positive
Tests
Recommendations and Treatment
Resources
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Self-management (no use at times prior to
parenting time)
Drug Testing/Monitored Antabuse
AA, CA, NA, LifeRing
Individual, family or group counseling
Intensive Outpatient Program or Inpatient Tx
Psychiatric Referral for consultation/medication
DSM-IV criteria
Substance dependence
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Tolerance of the substance
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Withdrawal
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More amounts, no efforts to control
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Time and resources spent obtaining substance
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Outside activities fall away
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Continued use in spite of significant problems
DSM-IV criteria
Substance abuse
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Failure to fulfill major obligations
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Physically dangerous situations
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Related legal problems
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Persistent or recurrent social or interpersonal
problems
A person is either dependent or abusing a particular
substance, not both at the same time
American Psychiatric Association DSM-V
Substance-Use Disorder:
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A. A maladaptive pattern of substance use leading to clinically
significant impairment or distress, as manifested by 2 (or more) of
the following, occurring within a 12-month period:
recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or
poor work performance related to substance use; substance-related
absences, suspensions, or expulsions from school; neglect of
children or household)
recurrent substance use in situations in which it is physically
hazardous (e.g., driving an automobile or operating a machine when
impaired by substance use)
continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the
effects of the substance (e.g., arguments with spouse about
consequences of intoxication, physical fights)
American Psychiatric Association DSM-V
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tolerance, as defined by either of the following:
a. a need for markedly increased amounts of the substance to
achieve intoxication or desired effect
b. markedly diminished effect with continued use of the same
amount of the substance
(Note: Tolerance is not counted for those taking medications under
medical supervision such as analgesics, antidepressants, ant-anxiety
medications or beta-blockers.)
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withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the substance (refer
to Criteria A and B of the criteria sets for Withdrawal from the
specific substances)
b. the same (or a closely related) substance is taken to relieve or
avoid withdrawal symptoms
(Note: Withdrawal is not counted for those taking medications
under medical supervision such as analgesics, antidepressants, antianxiety medications or beta-blockers.)
American Psychiatric Association DSM-V
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amounts over a longer period than was intended
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a great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
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important social, occupational, or recreational activities are given up
or reduced because of substance use
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the substance use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is likely
to have been caused or exacerbated by the substance
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Craving or a strong desire or urge to use a specific substance
American Psychiatric Association DSM-V
Severity specifiers:
• Mild: Presence of 2-3 symptoms
 Moderate: Presence of 4-5 symptoms
 Severe: Presence of 6 or more symptoms
 Specify if:
 With Physiological Dependence: evidence of
tolerance or withdrawal (i.e., either Item 10 or 11 is
present)
 Without Physiological Dependence: no evidence of
tolerance or withdrawal (i.e., neither Item 10 nor 11
is present)
DSM-V CONTINUED
• Specify if:
In early remission
In sustained remission
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Relapse
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Now recognized to be standard piece of the road to
recovery
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How will this affect your recommendations?
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How can safety be provided for the child?
MEDICAL MARIJUANA ISSUES
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Marijuana is illegal under federal law
Regulation of the industry is on-going and
evolving
Medical marijuana is a political, legal, health and
moral issue
Do people really qualify or do they just want to
get high?
Should drug abuse be treated as a health issue,
a legal issue, a moral issue or all?
MEDICAL MARIJUANA ISSUES
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What or has anything changed in assessing cannabis use with medical
marijuana recommendations?
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Right to use in Colorado but not a Right to be Impaired when parenting
children!
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Dosing Issues (Smoking, Vaporizers, Edibles, Tinctures, Oils)
Right to Use vs. Impact on Personality Functioning (Impact on Parenting
Capacity)
Research-What we know about impact on Executive Functioning/Motor
Skills
Marijuana and Tolerance and Adaptation to use?
MEDICAL MARIJUANA ISSUES
• Previous History of Cannabis Use/Abuse/Dependence? Prior to Card?
• Environmental Concerns, Exposure of Children to smoke (clothes/backpacks),
cannabis and edibles unlocked at home (infants/toddlers/pre-schoolers)
• Impact on Emotional and Behavioral Attunement of Parents
with children (Ability of Parent to regulate emotions and reflect on child?)
• Aspirational aspects of having parents not use 12 hours or longer or during
parenting time; Window of Detection Issues (Can this be enforced or
monitored?)
• Can we regulate prescriptions? (No control over their dosing)
MEDICAL MARIJUANA ISSUES
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Is there a documented history of debilitating disorders?
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Is using medicinal cannabis the best practices for the medical issue?
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How is assessment the same or different for pain medications and medical
marijuana?
When should a pain specialist be used for pain assessment or when to use
an IME (Independent Medical Evaluation)?
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Medical Marijuana and CPS (neglect and abuse?)
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Medical Marijuana Use and DUID’s (Children in vehicle)
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How do we safeguard children from parents that use cannabis regularly?
Can we?
Each case is ideographic and unique, case by case basis for MM &
Amendment 64 Recreational Use
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