Mental Health; Substance Abuse; & the Child Protection System

1. Mental Health; Substance Abuse; & the Child Protection System Michael L Haney Ph.D, NCC, CISM, LMHC Forensic and Mental Health Consultant Executive Director The American Professional Society on the Abuse of Children September 8, 2011 www.apsac.org

2. Objectives • Child Protective Investigators and Law Enforcement investigators are challenged to respond to child maltreatment allegations, which are often complicated when one or more of the child's caretakers has a substance abuse issue or mental disorder, including personality disorders. • This presentation provides an overview of the most common types of disorders and offers strategies for responding to the needs of the families • Explores the assessment of risk when mental illness or substance use/abuse is present in the home. • Participants will be encouraged to participate through media, didactic material and group interaction and scenario discussion.

3. Categories • Mood Disorder • Psychotic Disorders • Personality Disorders • Substance Use/Dependence

4. Risk Factors • History of mental health problems with an impact on functioning; • Unmanaged mental health problems with an impact on functioning; • Maladaptive coping strategies: • Misuse of drugs, alcohol, or medication; • Severe eating disorders; • Self-harm and suicidal behavior; • Lack of insight into illness and impact on child; • Non-compliance with treatment; • Poor engagement with services;

5. Risk Factors • Previous or current compulsory admissions to mental health hospital; • Disorder deemed long term ‘untreatable’, or untreatable within timescales compatible with child’s best interests; • Mental health problems combined with domestic abuse and/or relationship difficulties; • Mental health problems combined with isolation and/or poor support networks; • Mental health problems combined with criminal offending (forensic); • Non-identification of the illness by professionals (e.g. untreated post-natal depression can lead to significant attachment problems); • Previous referrals to Social Services/Child Protection

6. Risk Factors Some of the key findings in one review of 161 cases (47 in-depth case studies) revealed: • domestic violence was present in 66% of cases • substance misuse was present in 57% of cases • mental ill health was present in 55% of cases • All three issues were present in 34% of cases.

7. Risk Factors • serious neglect of the child and/or impairment to the point of not caring for the child • any history of domestic violence • A history of issues with regard to safeguarding adults • Any history of substance misuse by parent(s), visiting family members, friends, or other caregivers • Any history of significant personality disorder in a parent/caregiver.

8. Risk Factors • Hx or current psychotic beliefs, particularly if involving the child • persistent negative views expressed about a child, including rejection • ongoing emotional unavailability, unresponsiveness and neglect, including lack of praise and encouragement, lack of comfort and love and lack of age-appropriate stimulation • inability to recognize a child’s needs and to maintain appropriate parent-child boundaries

9. Risk Factors • ongoing use of a child to meet a parent’s own needs • distorted, confusing or misleading communications with a child including involvement of the child in the parent’s symptoms or abnormal thinking. (i.e., delusions targeting the child, incorporation into a parent’s obsessive cleaning/contamination rituals, or a child kept at home due to excessive parental anxiety or agoraphobia • ongoing hostility, irritability and criticism of the child or adolescent, inconsistent and/or inappropriate expectations of child

10. Crossing BridgesThe Family Model 4 Stressors & vulnerabilities 1 Adult mental health 2 Child dev & mental health 3 Parental & fam relationships 4 Strengths, resilience & resources

11. Types of disorders - Children • Mood Disorders • Depression • Dysthymia • Bi-Polar Disorder • Bi-Polar Disorders – manic; depressed; mixed; NOS • Oppositional Defiant Developmental • Autism Spectrum Disorders • Developmental Delays • ADHD Substance Abuse/Dependence • Poly Substance Use/Dependence • Alcohol Abuse/Dependence • Marijuana Abuse/Dependence • Conduct Disorder (Personality Disorder < 18) • Post Traumatic Stress Disorder

12. Types of Disorder – Adults • Mood Disorders: • Major Depression w/or wo S/H ideation • Bi-Polar Disorders 1 & 2 • Cyclothymia • Adjustment Disorders • Anxiety • Depressed Mood • Mixed • Emotion & Conduct • Unspecified

13. Substance Use/Abuse/Dependence • Poly Substance Use/dependence • Alcohol Abuse/Dependence • Marijuana Abuse/Dependence • Other drugs, etc

14. Psychotic Disorders: • Schizophrenia – various types • Paranoid • Disorganized • Catatonic • Undifferentiated • NOS

15. Personality Disorders • Borderline • Histrionic • Paranoid • Anti Social • Narcissistic • Avoidant • Dependent • Obsessive-Compulsive • NOS

16. PTSD • Frequently having upsetting thoughts or memories about a traumatic event. • Having recurrent nightmares. • Acting or feeling as though the traumatic event were happening again, sometimes called a "flashback." • Having strong feelings of distress when reminded of the traumatic event. • Being physically responsive, such as experiencing a surge in your heart rate or sweating, to reminders of the traumatic event. • Thoughts or actions – self-harm, cutting, burning, etc.

17. Avoidance Symptoms • Making an effort to avoidthoughts, feelings, or conversations about the traumatic event. • Making an effort to avoid places or people that remind you of the traumatic event. • Having a difficult time remembering important parts of the traumatic event. • A loss of interest in important, once positive, activities. • Feeling distant from others. • Experiencing difficultieshavingpositivefeelings, such as happiness or love.

18. Personality Disorders • Borderline – • characterized by a lack of ones own identity • with rapid changes in mood, • intense unstable interpersonal relationships,  • marked impulsively,  • instability in affect,  • and instability in self image. • ONSET:  Early adulthood and with a variety of contexts.

19. Personality Disorders • AntiSocial: • Antisocial personality disorder is characterized by a lack of regard for the moral or legal standards in the local culture.  • There is a marked inability to get along with others or abide by societal rules.  • Individuals with this disorder are sometimes called psychopaths or sociopaths. • Since the age of fifteen there has been a disregard for and violation of the right's of others, those right's considered normal by the local culture,  as indicated by at least three of the following: • Repeated acts that could lead to arrest. • Conning for pleasure or profit,  repeated lying,  or the use of aliases. • Failure to plan ahead or being impulsive.

20. Personality Disorders • Histrionic Personality Disorder is primarily characterized by: • exaggerated displays of emotional reactions, approaching theatricality, in everyday behavior.  • Emotions are expressed with extreme and often inappropriate exaggeration.  • Persons with this disorder are prone to sudden and rapidly shifting emotion expressions. • ONSET:  Early adulthood and with a variety of contexts.

21. Depressions - • Depression comes in different forms and affects many people differently. Some common signs include: • A sense of being "blue" or sad. • Wanting to be along • Persistent irritability • Difficulty and even avoiding making decisions • Difficultysleeping or excessive sleeping (not wanting to get out of bed) • Changes in appetite, either increased or decreased food intake. • Decreased libido • Anhedonia (inability to enjoy doing the things that are normally enjoyable • Length of course • Suicidal/Homicidal ideations

22. So what do we do? • CPS and mental health professionals must identify clients who are pregnant and those who are parents or who have regular access to children, whether they reside with children or not. • Professionals should consider the needs of all children as part of their assessments with CPS. • When adult mental health services and children’s services are both involved with a family, joint assessments should be carried out to assess the support parents need and the risk of harm to the child/ren • Coordination and guidance between all service providers, including multi-disciplinary staffings and follow up • Where appropriate, children should be given an opportunity to contribute to assessments

23. So What Do We Do? • CPS must include ongoing monitoring of the needs and risk factors for the children concerned. • Partners should be invited to contribute if they are involved with a family or where risks and needs have been identified that justify their involvement. • Mental health professionals must be included in strategy meetings, child protection conferences or associated meetings. • Mental health inpatient services should have written policies regarding the welfare of children and particularly the visiting of inpatients by children. • Mental health professionals can assist with obtaining necessary consents and releases of information

24. What Is the Purpose of a Psychological Evaluation? • Aid the trier of fact – Dependency or Criminal • Obtain psychological information in a standardized manner • Use norm referenced information • Determine mental capacity • Help determine psychopathology • Make treatment suggestions

25. Why Are You Asking For A Psychological Evaluation? • What stage are you in the investigation/evaluation? • What kind of information is needed? • What are the goals of the evaluation? • What are the issues and can testing help? • Do the attorneys, Social Services, and Judge have common questions? • Do the attorneys, Social Services, and Judge have different questions? • What is the Nexus between the event and history?

26. Kinds of Evaluations in Abuse and Neglect Cases • Child Medical Evaluations (CPT exams) • Child Evaluations • Child and Family Evaluations • Child Mental Health Assessments • Child Forensic Interviews • Sex Offender Specific Evaluations (ATSA standards) • Adult Mental Health Evaluations • Parental Competency Evaluations • Substance Abuse Assessments/Evaluations

27. Contributing Factors in Poor Parenting • Poor physical health • Situational and chronic stress • Evaluation stress • Ambivalence and uncertainty • Lack of parenting knowledge and skills • Mental disorder or disability • Family systems issues

28. Three Types of Parental Competencies1 1. Capacity to Care Nurturing, involvement with care givers 2. Capacity to Protect Supervision, tolerance for frustration 3. Capacity to Change Intelligence, reactions to treatment 1Haynes, J.P. (2010). Parenting Assessment in Abuse, Neglect, and Permanent Wardship Cases. In Benedek, et al., Principles and practice of child and adolescent forensic mental health. Washington, DC: American Psychiatric Publishing, Inc.

29. Psycho-legal Questions about Parental Competency • Can the parent provide adequate stimulation? • Can the parent respond to the child’s physical and emotional needs? • Can the parent set appropriate limits and relate in a non-punitive way to the child? • Are there specific risk factors related to the parent’s functioning including mental capacity, mental illness, substance abuse, domestic violence?

30. Questions About Parenting and Child Reunification • Is the parent aware of the emotional factors in a child’s return? • Can the parent support the child in negotiating the complex factors involved in reunification? • Including stability, bonding, attachment to foster parent, social needs, academic needs

31. What Information Is Conveyed With a Mental Health Diagnosis? • Severity of the problem • Possibility of remediation • Optional kinds of treatment • Possibility of deterioration or relapse • Impact on functioning both in parenting and in broader context • Current level of functioning

32. What Information Is Not Conveyed With a Diagnosis? • Rarely explains causes of a given behavior • May or may not be related to functioning in parenting • Functioning may vary across time, despite the diagnosis • May be debatable • Not always helpful, but sometimes useful

33. What Should Be In An Evaluation Report? • Court order and identifying data • Sources of information (interviews, tests, records, contacts) • Psycho-legal questions • Answers to the psycho-legal questions • Additional recommendations • Interview material • Test results • Collateral information

34. Adult Interview • Social Background • Parenting Interview • Domestic Violence • Substance Abuse • Sexual Abuse • Cognitive Insights • Social appropriateness

35. Social Background Topics • Social History • Educational History • Relationship History • Mental Health History • Medical History • Legal History • Child Protective Services History

36. Parenting Interview • Child’s development • Perceived needs of the child • Knowledge of medical needs • Knowledge of educational needs • Basic nutritional knowledge • Need for child’s protection • Ways protection might take place

37. Parenting Interview (continued) 8. Discipline techniques 9. Perceptions about reunification 10. Reactions to interventions 11. Attainment of new skills

38. Special Topic Interviews2 • Substance Abuse Assessment • Domestic Violence • Physical Abuse • Sexual Abuse • Mental Health Assessment • Medication • Hospitalizations • Investment in treatment 2Sattler, J.M. (1998). Clinical and forensic interviewing of children and families: Guidelines for the mental health, education, pediatric, and child maltreatment fields. San Diego, Jerome M. Sattler, Publisher, Inc.

39. Tertiary Prevention:Treatment and Referral • Professionals need to know what they can handle through office counseling and when they need to refer families for help. • They must also be cognizant of the resources available in their community to address these risks. • This requires knowledge of the child welfare, emergency shelter and substance abuse treatment systems and how to make referrals to appropriate therapists and mental health professionals and ensure follow up. • CPS must be educated consumers of mental health services

40. Social and Systems Change:Keeping Up to Date With the Field • Professionals can be more effective advocates for systems change if they are knowledgeable about current prevention strategies. • In CPS practice, professionals can identify prevention opportunities within the population of families and children who come to their system but who are unsubstantiated or do not require that the children be taken into protective custody. • Professionals in clinical services and law enforcement can help prevention professionals and volunteers by recognizing the importance of their prevention work and participating in multidisciplinary training, thereby assisting in networking alliances between prevention and treatment fields.

41. Intellectual capacity as measured by IQ Direct measure of client performance Influenced by education Influenced by emotional factors Does not measure parenting abilities Adaptive functioning Reflects functioning in real world Assess: responsibility, coping Allows for comparative observations by others No more time consuming than IQ Used in conjunction with IQ tests Two Aspects of Mental Capacity

42. Parent-Child Interaction • Where? • When? • How? • Documentation? • Social compliance! • Team approach to case planning! • Education and transference of learning!

43. The Effects of CAN - • Physical Health Consequences - The immediate physical effects of abuse or neglect can be relatively minor (bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some cases the physical effects are temporary; however, the pain and suffering they cause a child should not be discounted. Meanwhile, the long-term impact of child abuse and neglect on physical health is just beginning to be explored. (ACE Study) • According to the National Survey of Child and Adolescent Well-Being (NSCAW), more than one-quarter of children who had been in foster care for longer than 12 months had some lasting or recurring health problem (Administration for Children and Families, Office of Planning, Research, and Evaluation [ACF/OPRE], 2004a).

44. The Effects of CAN • Poor physical health. Several studies have shown a relationship between various forms of household dysfunction (including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, & Carnes, 2007).

45. The Effects of CAN • Impaired brain development. Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (De Bellis & Thomas, 2003). These alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006) • NSCAW found more than three-quarters of foster children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed to less than half of children in a control sample (ACF/OPRE, 2004a).

47. The Effects of CAN • Behavioral Consequences • Not all victims of child abuse and neglect will experience behavioral consequences. However, behavioral problems appear to be more likely among this group, even at a young age. An NSCAW survey of children ages 3 to 5 in foster care found these children displayed clinical or borderline levels of behavioral problems at a rate of more than twice that of the general population (ACF, 2004b). Later in life, child abuse and neglect appear to make the following more likely: • Difficulties during adolescence. Studies have found abused and neglected children to be at least 25 percent more likely to experience problems such as delinquency, teen pregnancy, low academic achievement, drug use, and mental health problems (Kelley, Thornberry, & Smith, 1997). Other studies suggest that abused or neglected children are more likely to engage in sexual risk-taking as they reach adolescence, thereby increasing their chances of contracting a sexually transmitted disease (Johnson, Rew, & Sternglanz, 2006).

48. The Effects of CAN • Poor mental and emotional health. In one long-term study, as many as 80 percent of young adults who had been abused met the diagnostic criteria for at least one psychiatric disorder at age 21. • These young adults exhibited many problems, including depression, anxiety, eating disorders, and suicide attempts (Silverman, Reinherz, & Giaconia, 1996). • Other psychological and emotional conditions associated with abuse and neglect include panic disorder, dissociative disorders, attention-deficit/hyperactivity disorder, depression, anger, posttraumatic stress disorder, and reactive attachment disorder (Teicher, 2000; De Bellis & Thomas, 2003; Springer, Sheridan, Kuo, & Carnes, 2007).

49. The Effects of CAN • Juvenile delinquency and adult criminality. According to a National Institute of Justice study, abused and neglected children were 11 times more likely to be arrested for criminal behavior as a juvenile, 2.7 times more likely to be arrested for violent and criminal behavior as an adult, and 3.1 times more likely to be arrested for one of many forms of violent crime (juvenile or adult) (English, Widom, & Brandford, 2004). • Alcohol and other drug abuse. Research consistently reflects an increased likelihood that abused and neglected children will smoke cigarettes, abuse alcohol, or take illicit drugs during their lifetime (Dube et al., 2001). According to a report from the National Institute on Drug Abuse, as many as two-thirds of people in drug treatment programs reported being abused as children (Swan, 1998).

50. The Effects of CAN • Abusive behavior. Abusive parents often have experienced abuse during their own childhoods. It is estimated approximately one-third of abused and neglected children will eventually victimize their own children (Prevent Child Abuse New York, 2003). • Societal Consequences - While child abuse and neglect almost always occur within the family, the impact does not end there. Society as a whole pays a price for child abuse and neglect, in terms of both direct and indirect costs.