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Alcohol & Sub. Dep.: Family Struggling with Sobriety
Alcohol & Sub. Dep.: Family Struggling with Sobriety

Section 13
Major Treatment Approaches to Alcoholism & Chemical Dependency,
& Psychoeducational Group for Children

Question 13 | Answer Booklet | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Learning about Current Programs of Recovery, such as 12 Step Programs, and how Therapists can Effectively Utilize these Programs:
Major treatment approaches to alcoholism and chemical dependency

An unfortunate fact about the treatment of drug addiction is that it remains largely unutilized by most sufferers of this condition. Facts about the use of drug treatment include that less than 10% of people with a substance-abuse disorder and less than 40% of those with a substance-dependence disorder seek professional help. Those statistics do not seem to be associated with socioeconomic or other demographic traits but do seem to be associated with the presence of other mental-health problems (co-morbidity).

The primary goals of drug-abuse or addiction treatment (also called recovery) are abstinence, relapse prevention, and rehabilitation. During the initial stage of abstinence, an individual who suffers from chemical dependency may need help avoiding or lessening the effects of withdrawal. That process is called detoxification or "detox." That aspect of treatment is usually performed in a hospital or other inpatient setting, where medications used to lessen withdrawal symptoms and frequent medical monitoring can be provided. The medications used for detox are determined by the substance the individual is dependent upon. For example, people with alcohol dependence might receive medications like anti-anxiety or blood pressure medications to decrease palpitations and blood pressure, or seizure medications to prevent possible seizures during the detoxification process. For many drugs of abuse, the detox process is the most difficult aspect of coping with the physical symptoms of addiction and tends to last days to a few weeks. Medications that are sometimes used to help addicted individuals abstain from drug use long term also depend on the specific drug of addiction. For example, individuals who are addicted to narcotics like Percodan (a combination of aspirin and oxycodone hydrochloride) heroin, or Vicodin, Vicodin ES, Anexsia, Lorcet, Lorcet Plus or Norco (combinations of hydrocodone and acetaminophen) often benefit from receiving longer-acting, less addictive narcotic-like substances like methadone (Methadose). People with alcohol addiction might try to avoid alcohol intake by taking disulfiram (Antabuse), which produces nausea, stomach cramping, and vomiting when the individual consumes alcohol.

Often, much more challenging and time consuming than recovery from the physical aspects of addiction is psychological addiction. For people who may have less severe drug dependency, the symptoms of psychological addiction may be able to be managed in an outpatient treatment program. However, those who have a more severe addiction, have relapsed after participation in outpatient programs, or who also suffer from a severe mental illness might need the higher structure, support, and monitoring provided in an inpatient drug treatment center, sometimes called "rehab." Following such inpatient treatment, many people with this level of addiction can benefit from living in a sober living community, that is, a group-home setting where counselors provide continued sobriety support and structure on a daily basis.

Also important in the treatment of addiction is helping the parents, other family members, and friends of the addicted person refrain from supporting addictive behaviors (codependency). Whether providing financial support, making excuses or failing to acknowledge the addictive behaviors of the addict, discouraging such codependency of loved ones is a key component to the recovery of the affected individual. A focus on the addicted person's role in the family becomes perhaps even more acute when that person is a child or teenager, given that minors come within the context of a family in nearly every instance. Chemical dependency treatment for children and adolescents is further different from that in adults by the younger addict's tendency to need help completing their education and achieving higher education or job training compared to addicts who may have completed those parts of their lives before developing the addiction.

The treatment of dual diagnosis seems to be less effective when treatment of the individual's mental illness is separate from the treatment of his or her chemical dependency. More successful are integrated treatment programs that include interventions for both disorders. Such interventions are all the more improved by the inclusion of assessment, intensive case management, motivational interventions, behavior interventions, family treatment as well as services for housing, rehabilitation, and medication treatment.

Psychoeducational Group for Children from Drug-Involved Families
Growing up in a home where adults use drugs poses significant risks to the psychosocial development of children (Dore, Kauffman, Nelson-Zlupko, & Granfort, 1996; Hayford, Epps, & Dahl-Regis, 1988; Scherling, 1994). These risks have multiple sources. First and foremost are the risks to fetal development from drug exposure in utero, which may lead to low birthweight, physical deformities, mental retardation, and other problems (Behnke & Eyler, 1992; Finnegan & Kendall, 1992). Maternal drug use in pregnancy is often combined with poor nutrition and lack of prenatal care, compounding the risk of poor outcomes for these infants. Furthermore, children born to drug-involved parents may be inadequately nurtured physically and emotionally during their formative years (Hawley, Halle, Drasin, & Thomas, 1995; Williams-Petersen et al., 1994). Child welfare workers commonly receive reports of infants and small children left alone for hours or even days while drug-using parents seek their next high. Addicted parents may forget to feed their children, bathe them, or comb their hair. Children as young as three or four years old may function as caregivers for parents or younger siblings.

Children in drug-involved families are often exposed to, and themselves experience, physical and sexual violence and other forms of trauma (Jaudes, Ekwo, & Van Voorhis, 1995; Kelleher, Chaffin, Hollenberg, & Fischer, 1994). It is estimated that 60 percent to 80 percent of children currently entering the foster care system do so because of abuse or neglect associated with familial substance abuse (Barth, Courtney, Berrick, & Albert, 1994; Jaudes et al., 1995). Parents abusing stimulants such as crack cocaine are more prone to agitation and are easily irritated by a child's normal chatter and play. They may lash out verbally or physically as a result. Violence among drug-using adults is common and frequently observed by young children. Many such children have also witnessed their addicted mothers prostituting for drug money or have been prostituted themselves by parents desperate for their next hit.

Not all children living in drug-involved families suffer negative consequences, particularly those who experience compensatory caregiving. However, by the time they reach school age many of these children demonstrate cognitive delays (van Baar, 1990), attenuated attention spans, difficulties in concentration (Bauman & Dougherty, 1983), and emotional and behavioral problems (Hawley et al., 1995; Johnson, Bonney, & Brown, 1990-91), all of which make classroom functioning difficult and threaten school failure. Like their parents, they often have few internalized behavior controls and, as a result, disrupt the classroom. They may become easily frustrated and explosive, lack rudimentary social skills, and be physically aggressive or, alternatively, they may withdraw from others. Negative self-evaluation and low self-worth may result from rejection by teachers and classmates.

Despite widespread recognition of the risks that parental drug use poses to children, few resources are available to help such children. Most research and available treatments target chemically dependent adults to the exclusion of their children. Even in programs specifically designed for chemically dependent women and their children, programming to address the effects of parental drug use on children is frequently lacking. Our experience suggests that the treatment of children of drug-involved parents depends entirely on their parents' involvement in treatment. Once a parent leaves treatment, his or her child's opportunity for services ends. Erratic attendance, characteristic of adult substance abusers, translates into erratic attendance of their children in treatment as well. In short, we observed scarce, sporadic services for children from drug-involved families, a population at highest risk.

To address this need, we developed and tested a group intervention that could be readily applied in elementary schools and other community agencies where children's access to services is not dependent on parental attendance in drug treatment. Our research suggested that this intervention should be both therapeutic and preventive in nature, ameliorating already-existing problems as well as preventing further difficulties from developing in the future. The intervention would need to address the affective domain and the psychosocial elements such as attitudes, beliefs, and behavioral responses to parental drug use.

A review of the existing literature on interventions with latency-aged drug-exposed children, our target population, found that most well-developed, empirically validated interventions were either solely preventive in focus or if therapeutic in intent, were geared toward children from alcoholic families. In addition, effective prevention programs seldom targeted the early school-age population that we hoped to reach. They did, however, provide support for incorporating training in age-appropriate personal and social skills to enable children to cope with a broad range of situations likely to arise in drug-using environments. These include general problem-solving skills, skills for increasing self-control and self-esteem, strategies for managing anger and anxiety through alternative coping responses and relaxation techniques, and interpersonal-relations skills (Botvin & Botvin, 1992). Outcome studies indicate that structured, time-limited psychoeducational groups are effective in addressing related psychosocial problems of early school-age children, such as aggression (Eargle, Guerra, & Tolan, 1994), poor social skills (MacLennan, 1994), disruptive behavior in the classroom (Bilides, 1992), and sexual abuse (Hack, Osachuk, & DeLuca, 1994).

Also important to our concerns, none of the intervention models described in the literature focused specifically on children from economically depressed inner-city neighborhoods, the location of our study. This raised questions about the appropriateness of existing models for such children, as well as the possibility of differing treatment needs of children from families involved in illicit drug use where few of any compensatory community resources are available.

Intervention Design
Because we could find no empirically validated school-based interventions aimed specifically at latency-aged children from drug-abusing families, we used a developmental research model for designing and evaluating our intervention. This model prescribes a structured approach to developing innovative interventions in the human services (Thomas & Rothman, 1994), in which significant investment is made in predevelopment planning, including problem analysis and knowledge acquisition and synthesis (Rothman, 1989). The design and development (testing) stages that follow are recursive; that is, each informs the other until the intervention is refined and rigorously evaluated. Recently this model has been applied specifically to designing and implementing preventive interventions such as we aimed to developed (Dumka, Roosa, Michaels, & Suh, 1995).

The Intervention Model
In our revised intervention, each of the eight group sessions, an hour and a half in length, follows the same structured format. Children are greeted personally by the group leaders at the door as they enter the room and take their seats around a table. Each session begins with a review of the "group rules," which clearly convey expectations of behavior and interpersonal conduct during the session. The group rules are printed on a poster that everyone can see as they recite them together.

The second activity in every session is recitation of the "Four Cs": You didn't cause it; you can't control it; you can't cure it; you can be okay. The Four Cs, adapted from the literature on families of alcoholics, are intended to help ameliorate the pervasive guilt that children from substance-abusing families have been found to carry because of their interpretation of parental substance use as somehow their fault. The Four Cs also address children's "magical thinking" regarding cause and cure; children often believe if they were only better behaved or took better care of their parents, the parents would not abuse drugs. The final message the Four Cs is designed to convey is that there are things children can do in situations where familial drug abuse is occurring to protect and care for themselves.

Two other activities structured into the beginning of every group session are the "Name Game" and "Best and Worst." The purpose of the Name Game is to help children begin to see themselves as worthy individuals with positive attributes. Best and Worst enables children to learn to share their experiences with others and to give and receive support from peers. These activities are designed to address the negative self-concepts and social isolation often observed in children from substance-abusing families.

Every group session ends with two activities also designed to enhance peer involvement and individual affirmation. One is a closing circle with a special handshake and goodbye statement recited in unison; the other requires the children to leave the room after speaking personal goodbyes to each of the group leaders. The group leaders use this opportunity to verbally reinforce each participant's positive behavior during the session.

In addition to repetition of the opening and closing activities, there are two brief activities in each session designed to highlight and address psychosocial issues of concern. For example, in the second group session, leaders present a large chart with pictures of faces expressing a variety of feelings. Group members each identify a feeling from the chart that they have experienced and share it with the group. The purpose of the exercise is to help children recognize a range of different feelings, put names to those feelings, and gain skill in verbalizing feelings rather than acting them out. This sedentary exercise is followed by a more active one that reinforces the learning: "Simon Says," using expression of the feelings they have just identified rather than touching parts of the body as in the usual "Simon Says."

Other activities structured into group sessions include reading a story about a boy whose big sister is using drugs and discussing it; writing a letter to the boy in this story, giving him suggestions of things he could do when he felt upset or scared about his sister's drug involvement; taking a large sheet of paper, folded in half, and drawing on one side of the page a person using drugs and on the other side of the page the same person not using drugs.

Each group activity is accompanied by a discussion of the main ideas or concepts. It is in these discussions that the worries and fears of participants come to the fore. Common themes that emerged in our groups included: disappointment when mom or dad did not keep promises; hurt when a parent said mean things when they were high; fears over what a parent would do when high; fear because a substance-abusing parent was not aware that someone else was touching them inappropriately; shame that their family was not a "normal" one; appreciation for the good things a parent would do for them when sober; and deep love for a parent despite drug use. Children whose parents were in recovery also identified powerful feelings, including anger that mom or dad is "so busy with recovery they don't have time for me," and unresolved pain over things that happened before a parent got sober. With assistance from the group leaders, participants helped each other express grief over these situations, validated one another's needs for emotional support, and brainstormed strategies for coping.
- Dore, Martha, Nelson-Zlupko, Lani, & Eda Kaufmann, ‘Friends in Need’: Designing and Implementing a Psychoeducational Group for School Children from Drug-Involved Families, Social Work, Mar 1999, Vol. 44, Issue 2.
- Roxanne Dryden-Edwards, MD., Melissa Conrad Stöppler, MD, Drug Abuse and Addiction, http://www.medicinenet.com/drug_abuse/article.htm

Personal Reflection Exercise #4
The preceding section contained information about psychoeducational groups for children from drug-involved families.  Write three case study examples regarding how you might use the content of this section in your practice.

Not all children living in drug-involved families suffer negative consequences such as abuse and neglect, particularly those who experience compensatory caregiving. However, what do these children often experience by the time they reach school age?
To select and enter your answer go to Answer Booklet.


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