child & family investigator colorado substance use disorders armand lebovits, lcsw, cac iii...
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Child & FamilyInvestigatorColorado
Substance Use Disorders
Armand Lebovits, LCSW, CAC III
Substance Abuse
• CJD 04-08 Standard 13
• CFIs no longer “routinely” conduct testing
• Make recommendations to court for testing
and/or evaluation if appropriate
• Done by CFI only if sole issue of appointment,
and if qualified
Substance Abuse
• An enormous problem
• More than one in 10 in US live with
dependent or abusing parents
• Profound effects on the children
Effects on Parenting
• The effects of Substance Abuse on Parenting
• Parent unavailable to child
• Parent disappears
• Parent wastes the resources of the family
• Unstable housing, community and schools
• Criminal activity, child endangerment
• Child more likely to abuse
What the Child experiences
• Broken promises
• Inconsistency and unpredictability
• Shame and humiliation
• Tension and fear
• Paralyzing guilt and an unwarranted sense of responsibility
• Anger and hurt
• Loneliness and isolation
• Lying as a way of life
• Feeling Responsible and obligated
CHARACTERISTICS OF AN ADDICTIONCHARACTERISTICS OF AN ADDICTION
DENIALDENIAL IMPULSIVITY-SENSE OF IMMEDIACYIMPULSIVITY-SENSE OF IMMEDIACY COMPULSION TO USECOMPULSION TO USE LOSS OF CONTROLLOSS OF CONTROL TOLERANCETOLERANCE WITHDRAWAL OF USE (OR WITHDRAWAL OF USE (OR
BEHAVIOR) LEADS TO DISCOMFORTBEHAVIOR) LEADS TO DISCOMFORT PROGRESSION OVER TIMEPROGRESSION OVER TIME
UNDERSTANDING SUBSTANCE UNDERSTANDING SUBSTANCE USE AND DISORDERS:USE AND DISORDERS:
DSM V DIAGNOSTIC CRITERIA (Slides 21-27)DSM V DIAGNOSTIC CRITERIA (Slides 21-27) CONTINUUM OF USE MODELCONTINUUM OF USE MODEL
-NO USE/NON-PROBLEM, -NO USE/NON-PROBLEM, SOCIAL/RECREATIONAL USE, MISUSE,SOCIAL/RECREATIONAL USE, MISUSE,BINGE USE, ABUSE, DEPENDENCEBINGE USE, ABUSE, DEPENDENCE
CO-OCCURRING M.H. DISORDERS ANDCO-OCCURRING M.H. DISORDERS ANDS.A. DISORDERSS.A. DISORDERS
DEFENSE MECHANISMSDEFENSE MECHANISMS IMPACT ON COGNITIVE, PSYCH. & SOCIAL IMPACT ON COGNITIVE, PSYCH. & SOCIAL
SYSTEMS SYSTEMS
CONTINUUM OF USE MODELCONTINUUM OF USE MODEL
Social/RecreationalSocial/Recreational Heavy Drinking/Problem Drinker Heavy Drinking/Problem Drinker MisuseMisuse Sustained vs. Periodic UseSustained vs. Periodic Use Abuse (Heavy Episodic Binging-5+ Abuse (Heavy Episodic Binging-5+
drinks)drinks) Dependence Dependence
(Psychological/Physiological)(Psychological/Physiological) Addiction/Addictive Behaviors Addiction/Addictive Behaviors
ADDICTION AS AN ATTACHMENT ADDICTION AS AN ATTACHMENT DISORDERDISORDER
A DISORDER IN SELF-REGULATIONA DISORDER IN SELF-REGULATION
DYSFUNCTIONAL ATTACHMENT STYLESDYSFUNCTIONAL ATTACHMENT STYLES
PADS VS. DAPS (PEOPLE ARE DRUG PADS VS. DAPS (PEOPLE ARE DRUG SUBSTITUTES vs. DRUGS ARE PEOPLE SUBSTITUTES vs. DRUGS ARE PEOPLE SUBSTITUTES)SUBSTITUTES)
THOSE DEPENDENT ON ADDICTIVE SUBSTANCESTHOSE DEPENDENT ON ADDICTIVE SUBSTANCES CANNOT REGULATE THEIR EMOTIONS, HAVE PROBLEMSCANNOT REGULATE THEIR EMOTIONS, HAVE PROBLEMS
WITH SELF-CARE, SELF-ESTEEM AND INTERPERSONALWITH SELF-CARE, SELF-ESTEEM AND INTERPERSONALRELATIONSHIPSRELATIONSHIPS
THE POPULATIONTHE POPULATION
PRE/POST DIVORCE – USUALLY HIGH CONFLICTPRE/POST DIVORCE – USUALLY HIGH CONFLICT OVERREACTION AROUND SUBSTANCE ABUSE/ OVERREACTION AROUND SUBSTANCE ABUSE/
DEPENDENCEDEPENDENCE TENDENCY FOR ONE OR BOTH PARTIES TO TENDENCY FOR ONE OR BOTH PARTIES TO
EMBELLISH OR MINIMIZE USE OF SELF/OTHEREMBELLISH OR MINIMIZE USE OF SELF/OTHER OFTEN DUAL-DIAGNOSIS ISSUES, TRAUMA…OFTEN DUAL-DIAGNOSIS ISSUES, TRAUMA… THERE MAY BE CRIMINAL AND CIVIL LEGAL THERE MAY BE CRIMINAL AND CIVIL LEGAL
ISSUES AT STAKEISSUES AT STAKE GENERALLY, THIS IS A RESISTIVE POPULATIONGENERALLY, THIS IS A RESISTIVE POPULATION
GOALS OF A SUBSTANCE USE GOALS OF A SUBSTANCE USE EVALUATIONEVALUATION
To understand theTo understand the role that a substance plays role that a substance plays in a personin a person’’s life/level of involvement with s life/level of involvement with the substancethe substance
To determineTo determine how the substance use impacts how the substance use impacts the personthe person’’s functionings functioning Cognitive: executive functioning, judgment, Cognitive: executive functioning, judgment,
decision-decision- making, tracking/monitoring, problem making, tracking/monitoring, problem solving, memory,solving, memory,
Psychological: mood, feelings, emotional regulation Psychological: mood, feelings, emotional regulation Social/Legal/OccupationalSocial/Legal/Occupational Medical/PhysicalMedical/Physical
To offerTo offer recommendations that can be recommendations that can be implemented into a parenting planimplemented into a parenting plan
To provide aTo provide a piece of the puzzlepiece of the puzzle for a larger for a larger evaluationevaluation
THE TRUTH IS RARELY PURETHE TRUTH IS RARELY PURE
AND NEVER SIMPLEAND NEVER SIMPLE
OSCAR WILDEOSCAR WILDE
WHAT GETS US INTO TROUBLEWHAT GETS US INTO TROUBLE
IS NOT WHAT WE DONIS NOT WHAT WE DON’’T KNOW,T KNOW,
ITIT’’S WHAT WE KNOW FOR SURES WHAT WE KNOW FOR SURE
THAT JUST AINT SO!THAT JUST AINT SO!
MARK TWAINMARK TWAIN
KEY CONSIDERATIONSKEY CONSIDERATIONS
Is the concern a current problem Is the concern a current problem (within the past 12 months)?(within the past 12 months)?
How much of a factor is the stress How much of a factor is the stress of the divorce?of the divorce?
Has use occurred during Has use occurred during parenting time/Does use impact parenting time/Does use impact parenting?parenting?
Documented history vs. Documented history vs. ““He said, He said, She saidShe said””??
KEY CONSIDERATIONSKEY CONSIDERATIONS
Past substance use and mental Past substance use and mental health treatment history/records?health treatment history/records?
Is concern based on single or Is concern based on single or multiple episodes?multiple episodes?
Meaning of allegations in the Meaning of allegations in the context of the divorce dynamics.context of the divorce dynamics.
Are there concerns about the Are there concerns about the credibility of the credibility of the accuser/allegations?accuser/allegations?
IMPLICATIONS FOR PARENTING PLANSIMPLICATIONS FOR PARENTING PLANS
Overall concern is keeping children safeOverall concern is keeping children safe
Do there need to be restrictions on Do there need to be restrictions on parenting time?parenting time?
Do the parents need treatment?Do the parents need treatment?
Do children and/or other family members Do children and/or other family members need treatment or support?need treatment or support?
IMPLICATIONS FOR PARENTING PLANSIMPLICATIONS FOR PARENTING PLANS
Overall concern is keeping children safeOverall concern is keeping children safe
Do there need to be restrictions on Do there need to be restrictions on parenting time?parenting time?
Do the parents need treatment?Do the parents need treatment?
Do children and/or other family members Do children and/or other family members need treatment or support?need treatment or support?
IMPLICATIONS FOR PARENTING PLANSIMPLICATIONS FOR PARENTING PLANS
Is limited substance use OK?Is limited substance use OK?
What defines relapse/How to What defines relapse/How to respond?respond?
Is monitoring necessary?Is monitoring necessary?
IMPLICATIONS FOR PARENTING IMPLICATIONS FOR PARENTING
PLANSPLANS:: MONITORING STRATEGIESMONITORING STRATEGIES What Tests to Use:What Tests to Use:
Breath/Saliva testingBreath/Saliva testing Urine testingUrine testing Blood testingBlood testing Hair testingHair testing Transdermal (Sweat)Transdermal (Sweat)
Frequency of Testing: Random or FixedFrequency of Testing: Random or Fixed Duration of TestingDuration of Testing Response to Missed, Dilute or Positive Response to Missed, Dilute or Positive
TestsTests
Recommendations and Treatment Recommendations and Treatment ResourcesResources
Self-management (no use at times prior to Self-management (no use at times prior to parenting time)parenting time)
Drug Testing/Monitored AntabuseDrug Testing/Monitored Antabuse AA, CA, NA, LifeRingAA, CA, NA, LifeRing Individual, family or group counselingIndividual, family or group counseling Intensive Outpatient Program or Inpatient Intensive Outpatient Program or Inpatient
TxTx Psychiatric Referral for Psychiatric Referral for
consultation/medicationconsultation/medication
DSM-IV criteria
• Substance dependence
• Tolerance of the substance
• Withdrawal
• More amounts, no efforts to control
• Time and resources spent obtaining substance
• Outside activities fall away
• Continued use in spite of significant problems
DSM-IV criteria
• Substance abuse
• Failure to fulfill major obligations
• Physically dangerous situations
• Related legal problems
• 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 American Psychiatric Association DSM-V
Substance-Use DisorderSubstance-Use Disorder:: A. A maladaptive pattern of substance use leading to A. A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as manifested by clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month 2 (or more) of the following, occurring within a 12-month period: period:
recurrent substance use resulting in a failure to fulfill major recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from substance-related absences, suspensions, or expulsions from school; neglect of children or household) school; neglect of children or household)
recurrent substance use in situations in which it is physically recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) machine when impaired by substance use)
continued substance use despite having persistent or continued substance use despite having persistent or recurrent social or interpersonal problems caused or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical with spouse about consequences of intoxication, physical fights)fights)
American Psychiatric Association DSM-V American Psychiatric Association DSM-V
tolerance, as defined by either of the following: tolerance, as defined by either of the following: a. a need for markedly increased amounts of the a. a need for markedly increased amounts of the
substance to achieve intoxication or desired effect substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the b. markedly diminished effect with continued use of the
same amount of the substancesame amount of the substance(Note: Tolerance is not counted for those taking (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)antidepressants, ant-anxiety medications or beta-blockers.)
withdrawal, as manifested by either of the following: withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the a. the characteristic withdrawal syndrome for the
substance (refer to Criteria A and B of the criteria sets for substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) Withdrawal from the specific substances)
b. the same (or a closely related) substance is taken to b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptomsrelieve or avoid withdrawal symptoms(Note: Withdrawal is not counted for those taking (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)antidepressants, anti-anxiety medications or beta-blockers.)
American Psychiatric Association DSM-V American Psychiatric Association DSM-V
• amounts over a longer period than was intended
• a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects
• important social, occupational, or recreational activities are given up or reduced because of substance use
• 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
• Craving or a strong desire or urge to use a specific substance
American Psychiatric Association DSM-V American Psychiatric Association DSM-V
Severity specifiersSeverity specifiers::
•• Mild: Presence of 2-3 symptomsMild: Presence of 2-3 symptoms Moderate: Presence of 4-5 symptomsModerate: Presence of 4-5 symptoms Severe: Presence of 6 or more symptomsSevere: Presence of 6 or more symptoms SpecifySpecify if: if: With Physiological Dependence: evidence of With Physiological Dependence: evidence of
tolerance or withdrawal (i.e., either Item 10 or 11 is tolerance or withdrawal (i.e., either Item 10 or 11 is present)present)
Without Physiological Dependence: no evidence of Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 10 nor 11 tolerance or withdrawal (i.e., neither Item 10 nor 11 is present)is present)
Relapse
• Now recognized to be standard piece of the road to recovery
• How will this affect your recommendations?
• How can safety be provided for the child?
MEDICAL MARIJUANA ISSUESMEDICAL MARIJUANA ISSUES
Marijuana is illegal under federal lawMarijuana is illegal under federal law Regulation of the industry is on-going and Regulation of the industry is on-going and
evolvingevolving Medical marijuana is a political, legal, Medical marijuana is a political, legal,
health and moral issuehealth and moral issue Do people really qualify or do they just Do people really qualify or do they just
want to get high?want to get high? Should drug abuse be treated as a health Should drug abuse be treated as a health
issue, a legal issue, a moral issue or all?issue, a legal issue, a moral issue or all?
MEDICAL MARIJUANA ISSUESMEDICAL MARIJUANA ISSUES
•• What or has anything changed in assessing cannabis use with What or has anything changed in assessing cannabis use with medical marijuana recommendations?medical marijuana recommendations?
•• Right to use in Colorado but not a Right to be Impaired when Right to use in Colorado but not a Right to be Impaired when parenting children!parenting children!
Dosing Issues (Smoking, Vaporizers, Edibles, Tinctures, Oils)Dosing Issues (Smoking, Vaporizers, Edibles, Tinctures, Oils)
Right to Use vs. Impact on Personality Functioning (Impact on Right to Use vs. Impact on Personality Functioning (Impact on Parenting Capacity)Parenting Capacity)
Research-What we know about impact on Executive Research-What we know about impact on Executive
Functioning/Motor SkillsFunctioning/Motor Skills
Marijuana and Tolerance and Adaptation to use?Marijuana and Tolerance and Adaptation to use?
MEDICAL MARIJUANA ISSUESMEDICAL 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 ISSUESMEDICAL MARIJUANA ISSUES Is there a documented history of debilitating disorders?Is there a documented history of debilitating disorders?
Is using medicinal cannabis the best practices for the medical issue? Is using medicinal cannabis the best practices for the medical issue?
How is assessment the same or different for pain medications and medical How is assessment the same or different for pain medications and medical marijuana?marijuana?
•• When should a pain specialist be used for pain assessment or when to use an IME When should a pain specialist be used for pain assessment or when to use an IME (Independent Medical Evaluation)? (Independent Medical Evaluation)?
•• Medical Marijuana and CPS (neglect and abuse?)Medical Marijuana and CPS (neglect and abuse?)
•• Medical Marijuana Use and DUIDMedical Marijuana Use and DUID’’s (Children in vehicle)s (Children in vehicle)
•• How do we safeguard children from parents that use cannabis regularly? Can we?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 Each case is ideographic and unique, case by case basis for MM & Amendment 64 Recreational Use64 Recreational Use