Child Family Investigator Colorado Armand Lebovits LCSW CAC

Child & Family Investigator Colorado Armand Lebovits, LCSW, CAC III armandlebovitslcsw@gmail. com Substance Use Disorders

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 ADDICTION n n n n 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: n n DSM V DIAGNOSTIC CRITERIA (Slides 21 -27) CONTINUUM OF USE MODEL -NO USE/NON-PROBLEM, SOCIAL/RECREATIONAL USE, MISUSE, BINGE USE, ABUSE, DEPENDENCE n n n CO-OCCURRING M. H. DISORDERS AND S. A. DISORDERS DEFENSE MECHANISMS IMPACT ON COGNITIVE, PSYCH. & SOCIAL SYSTEMS

CONTINUUM OF USE MODEL n n n n 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 n A DISORDER IN SELF-REGULATION n DYSFUNCTIONAL ATTACHMENT STYLES n n PADS VS. DAPS (PEOPLE ARE DRUG SUBSTITUTES vs. DRUGS ARE PEOPLE SUBSTITUTES) THOSE DEPENDENT ON ADDICTIVE SUBSTANCES n CANNOT REGULATE THEIR EMOTIONS, HAVE PROBLEMS WITH SELF-CARE, SELF-ESTEEM AND INTERPERSONAL RELATIONSHIPS

THE POPULATION n n n 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 n n 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 n n n 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 n n 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 n n 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 n n 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 n n 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 n n n Is limited substance use OK? What defines relapse/How to respond? Is monitoring necessary?

IMPLICATIONS FOR PARENTING PLANS: n n MONITORING STRATEGIES What Tests to Use: n n n n 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 n n n Self-management (no use at times prior to parenting time) Drug Testing/Monitored Antabuse AA, CA, NA, Life. Ring Individual, family or group counseling Intensive Outpatient Program or Inpatient Tx Psychiatric Referral for consultation/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 Substance-Use Disorder: n n 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 n n n 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. ) n n n 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, anti-anxiety medications or beta-blockers. )

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 Severity specifiers: • Mild: Presence of 2 -3 symptoms n Moderate: Presence of 4 -5 symptoms n Severe: Presence of 6 or more symptoms n Specify if: n With Physiological Dependence: evidence of tolerance or withdrawal (i. e. , either Item 10 or 11 is present) n 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 27

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 ISSUES n n n 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 • What or has anything changed in assessing cannabis use with medical marijuana recommendations? • Right to use in Colorado but not a Right to be Impaired when parenting children! n n Dosing Issues (Smoking, Vaporizers, Edibles, Tinctures, Oils) Right to Use vs. Impact on Personality Functioning (Impact on Parenting Capacity) n Research-What we know about impact on Executive Functioning/Motor Skills n 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 n Is there a documented history of debilitating disorders? n Is using medicinal cannabis the best practices for the medical issue? n • 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)? • Medical Marijuana and CPS (neglect and abuse? ) • Medical Marijuana Use and DUID’s (Children in vehicle) 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 • •