When Parents use Methamphetamines: Strategies for working with Children

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When Parents use Methamphetamines Strategies for
working with Children

• Debra Eisert
• OHSU and University of Oregon

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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

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Objectives

• Learn how prenatal methamphetamine exposure
  impacts children
• Learn how methamphetamine use by adult caretakers
  impacts children
• Strategies for addressing behavioral challenges.

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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

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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

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Images of meth use
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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

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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)

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Big Ideas (contd)

• 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

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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
• Cant always separate impact of substance use and
  environment

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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.

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Meth Use in the U.S.
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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.
• www.oregondec.org/OregonMethLabStats.pdf

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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.

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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

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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

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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
• http//www.ncsacw.samhsa.gov/resources/substance-e
  xposed-infants.aspx

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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

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Common Infant Symptomsany 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)

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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
• http//health.utah.gov/meth/html/Healthconcerns/Ch
  ildren.html

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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

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IDEAL Contd

• 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

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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

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Toddlers (Contd)

• 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

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Toddlers (contd)

• 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

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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

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Case contd

• 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

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Interventions for Child

• Consistent home environment, with known
  caregivers
• Reduce overstimulation
• Divert attention when mildly upset
• Teach Self calming
• Consistent interventions across caregivers

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Interventions (contd)

• Feeding therapy
• Speech/language therapy (EI)
• OT for sensory problems
• Attachment therapy
• Good sleep hygiene, monitor, consider melatonin
  if needed

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IDEALstudy 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

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IDEAL contd

• 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.

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Tobacco

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

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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)

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M Moms in IDEAL study

• More likely to be single,
• Live in household with lt 10,000 income
• Tend to be younger,
• Have fewer, and later prenatal visits
• Gain more weight

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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)

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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

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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

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12 core principles (contd)

• 5. Vary the rewards to prevent boredom
• 6. ACT, dont 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

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12 core principles

• 10. Maintain a set of priorities. Ignore minor
  rule violations
• 11. Dont personalize the childs problem.
  Maintain a sense of humor
• 12. Practice forgiveness, be a mother not a
  martyr.
• (From Russell Barkley, no date)

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School aged children

• Social emotional regulation
• Secondary diagnoses
• Trauma
• Team evaluation (educational or medical)
• Classroom adjustments
• Permanency
• Counseling

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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

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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

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Characteristics of Moms(Any substance)

• New Zealand Study of Moms referred to Alcohol and
  Drug Study Team (2001-2003)
• 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.

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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

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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

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Additional sources of trauma

• Weapons
• Violence against siblings
• Stranger violence
• Removal from home and decontamination if lived in
  lab

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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.

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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

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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

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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.

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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

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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

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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

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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

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Implications (contd)

• 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)

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Neglect is Powerful

• Health consequences
• Psychological consequences
• Relationship Difficulties
• Behavioral consequences
• Significant impact on attachments of young
  children.

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What Adults can tell us

• Interviewed 35 adult informants with a variety of
  roles
• Informants described childrens 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 . . .

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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

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Individual differences

• Differences may be due to
• Temperament, intelligence, resilience
• Extended Family
• Community (e.g., school practices)

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Childrens 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)

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Childrens Reports(contd)

• 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)

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Childrens 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

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Implications for Foster Families

• Expect divided loyalties and dont 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.

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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)

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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
• http//eip.uoregon.edu/projects.feat

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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

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Lane County Activities

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

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Established workgroups

• Prenatal screening
• Hospital Policy
• Substance exposed newborn team
• Postnatal supports
• Project FEAT

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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
• http//aia.berkeley.edu/training/SEN2010/sen_agend
  a.php

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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.

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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)

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Questions?