Women, Addiction and Mental Health Issues in the Drug Courts

Hon. Peggy Fulton Hora Judge of the Superior Court (Ret.) LADCP April 11, 2012

 “There is nothing more unequal then the equal treatment of unequal people” Thomas Jefferson

Female drug use

 Approximately 6.6% of women aged 12 and older reported past month use of an illicit drug  9,417,840 females Substance Abuse and Mental Health Services Administration, 2009 National Survey on Drug Use and Health (NSDUH) , September 2010)

Women and Alcohol

  2.7 million women abuse alcohol “moderate” drinking is < 1 drink a day  4 million women need treatment for substance dependence

1:4 cases of dementia caused by alcohol

  Women are at high risk because more susceptible to alcohol’s “brainwashing” effects Women are less able to deal with alcohol’s toxic effects  Develop more severe complications earlier   Younger drinkers will experience memory problems sooner Macrae Fiona,

Daily Mail Online,

May 11, 2009

Women and drugs in CJ system

 Women in the criminal justice system display an even higher rate of substance use  59.3% of state and 47.6% of Federal female prisoners surveyed in 2004 indicated that they had used drugs in the month prior to their offense  60.2% of state and 42.8% of Federal female prisoners surveyed in 2004 met drug dependence or abuse criteria BJA

Women and Smoking

 Women smokers get sicker at a younger age than men  COPD reduced lung function at lower level of smoking  “Cigarettes More Toxic for Women, Study Finds,” Join Together Online 5-20-09

“You’ve come a Long way, Baby”

LA Cost of SA and Addiction

 17% of Louisiana state budget = $1,375,626  $320.83 per capita “Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets,” CASA (May 2009)

The Burden on SA/Addiction in LA

The Substance Abuse Dollar

Treatment 3 cents Regulation <1 cent 97 cents of every substance abuse dollar is spent on the burden of use

Impact on Kids

Females constitute approximately 30% of the substance addicted population in the United States and most are of childbearing age

500,000 - 750,000 newborns are exposed to illicit drugs each year

Among pregnant women aged 15 to 44 years who participated in the 2006 National Survey on Drug Use and Health, 4.0% reported having used illicit drugs within one month of the survey Josh Gunn, Ph.D. and Scott Kriger , Ph.D, “The Prevalence of Maternal Drug Use During Pregnancy”

Women/girls use for different reasons

 A three-year study on women and young girls (aged 8 –22) revealed that girls and young women use substances for different reasons than boys and young men.  Risk factors such as low self-esteem, peer pressure, and depression make girls and young women more vulnerable to substance use as well as addiction National Center on Addiction and Substance Abuse at Columbia University, The Formative Years: Pathways to Substance Abuse Among Girls and Young Women Ages 8 –22 (PDF) , February 2003

Juvenile prevalence

 Of youth in post-adjudication placements, 47% have alcohol and drug disorders  Among high school seniors in 2008, one in 10 (10.4%) reported that in the two weeks prior to their interview, they had driven a vehicle after smoking marijuana

Youth with MH/AOD problems

 Adolescents with serious behavioral problems are more than

7 x’s

more likely to report substance dependence  Youth with serious emotional problems are

4 x’s

more likely to report AOD dependence

Drug Cases Juvenile Courts

    193,700 juvenile drug cases 2004 1991-2004 drug cases doubled Delinquency caseload for drugs = 7% in 1985 vs. 12% in 2004 Female caseload jumped12% 20% ‘91-04

“Drug Offense Cases in Juvenile Courts, 1985-2004,” OJJDP Fact Sheet, Feb. 2008

Juvenile Justice

  Up to 67% of youth involved in the juvenile justice system have a substance use problem.

Almost ¾ of youth in correctional facilities report mental health problems during screening

Co-Occurring

 “[Co-Occurring] is the

expectation

, not an exception.”  Dr. Ken Minkoff

Co-Occurring disorders are more prevalent in men or women?

Women

Mental health issues

   Co-morbidity complicates and exacerbates the problems Almost 12% of mothers in the U.S. has serious mental illness; 3.2% had SMI + SA Up to 95% of parents in tx programs have co occurring disorders

Post Traumatic Stress Disorder

 30-57% women in treatment meet criteria for PTSD  45-85% of battered women meet criteria  Co-morbidity for PTSD and substance use disorders is 2-3xs higher for females

Trauma-informed Care

   Community corrections, prosecution, defense and the court must become “trauma-informed” Substance abuse and other mental health issues are closely associated with trauma SA/MH drives the justice system —both criminal and child abuse and neglect cases “Understanding women in court,” SAMHSA, Center on Women, Violence and Trauma (2006)

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

OAS, 2002 Women with Co-Occurring Primary Drugs of Choice

Alcohol Opiates Cocaine Marijuana Stimulant Other

Cocaine / Alcohol Abusers with Comorbid Psychiatric Disorder Anxiety Depression Bipolar Panic disorder Social phobia PTSD MEN 48% 36% 6% 10% 14% 24% WOMEN 70% 40% 4% 18% 10% 46%

Men vs. Women in Custody

  Women inmates have >symptomology diagnosed with mental health problems 3xs rate of men Symptoms Diagnosed SP M 48% 8% SP F 62% 23% Jail M 59% 9% Jail F 70% 23%

Women with Co-Occurring More Likely Than Men to be:  Poor  Uneducated  Poor job skills  Receive public assistance  Report more relatives with AOD problems  Care for more dependents  Depressed, anxious, have eating disorders and lower self-esteem “Women with Co-Occurring Mental Illness and Substance Abuse,” AIA Center (May 2005)

Post-Traumatic Stress Disorder (PTSD)   

Acute traumatic stress is caused by an individual's subjective experience of an extreme traumatic event which can lead to extreme stress that inhibits a person's ability to cope.

Trauma is defined as a terrifying event that a person experiences, witnesses or learns about in which grave physical harm occurred or was threatened. The traumatic event causes the person to feel intense fear, terror or a sense of helplessness. http://www.attcnetwork.org/learn/topics/ptsd/index.asp

Post Traumatic Stress Disorder

 30-57% women in treatment meet criteria for PTSD  45-85% of battered women meet criteria Co-morbidity for PTSD and substance use disorders is 2-3xs higher for females  Smokers at higher risk for PTSD 

Archives of General Psychiatry (

Nov. 05)

“Linda”

 41 years old  Alcoholic  Incest survivor but won’t talk about it  Battered by > one man  Dx? Tx? Action plan?

 What ?s

New app from VA

Women with Co-Occurring More Likely Than Men to be:  Poor  Uneducated  Poor job skills  Receive public assistance  Report more relatives with AOD problems  Care for more dependents  Depressed, anxious, have eating disorders and lower self-esteem “Women with Co-Occurring Mental Illness and Substance Abuse,” AIA Center (May 2005)

Allowing women to have their children with them while in treatment increases treatment success

TRUE

The number one barrier to treatment for women is:

Lack of child care and fear of losing their children

The number two barrier to treatment for women is:

Being battered

FALSE

The number one risk factor for alcoholism is childhood sexual abuse.

   

Childhood Sexual Abuse

It is the second most prevalent risk factor Applies to both boys and girls 70-90% of women in tx were sexually abused before age 16 7-16% men in jail report physical or sexual abuse before 18

Aristotle said,

“…women who drink wine excessively give birth to children who drink excessively of wine.” 350 B.C.

Becoming trauma-informed

   Community corrections, prosecution, defense and the court must become “trauma-informed” Substance abuse and other mental health issues are closely associated with trauma SA/MH drives the justice system —both criminal and child abuse and neglect cases Understanding women in court SAMHSA, Center on Women, Violence and Trauma (2006)

    48-90% women with SA/MH issues have histories of interpersonal abuse First occurrence when child or adolescent Intergenerational issues – survivors often lost custody of their own children due to abuse and neglect In dependency cases, AOD is present >50% of the time

Traumatic stress during childhood

    Can affect physical/mental health Relationships School performance Risk taking in childhood and as an adult

Summary of Physical /Sexual Assault Across the Lifespan (U.S.A.) National Figures (All U.S. Women) Women Living In Poverty Incarcerated Women Severe Physical Violence by Childhood Caretakers Before Age 18 Sexual Molestation in Childhood Before Age 16 (Any Perpetrator) Any Physical Violence or Sexual Molestation in Childhood

40% 20-27% Not Available

Severe Physical Violence by Adult Intimate Partners

22%

Physical Violence or Sexual Assault by Intimates over Lifespan

Not Available 63% 42% 72% 61% 83% 70% 59% 82% 75% 94%

25 years to grow a mature one

   18 25 “apprentice adults” Exposure to traumatic stress can affect developmental processes Increases risk of SA, criminal activity, homelessness and revictimization

Another recent survey showed:

   1:5 girls have been sexually or physically abused The abuse occurred at home (53%) It happened more than once (65%)     The abuser was a family member (57%) Or a family friend (13%) 29% told no one Have increased likelihood of SA or eating disorders

Tanya’s story

 “When I was a child, my father used to rape me. It started when I was nine…. After I ran away, I wanted somebody to want me. I ran into this guy, he was older, and I wanted him to want me. He gave me cocaine. I was 13.”  Quotation from Tanya, interview on 7/9/98, Hirsch, Amy E., “Some Days are Harder than Hard,” Welfare Reform and Women with Drug Convictions in Pennsylvania, Center for Law and Social Policy, (Dec. 1999)

  Age of Onset of Drinking Is a Risk Factor Every year before 21 increases likelihood of problem drinking by 12% Early drinkers need more alcohol to get high

45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Age 13: 42% Age 16: 22% Age 21: 10%

Adolescent Substance Abuse

 The younger an individual is at the onset of substance use, the greater the likelihood that a substance use disorder will develop and continue into adulthood.

 More than 90% of current substance abusers started using before the ago of 18; half started before age 15

Age of onset of drinking

   If first drink at 13, 47% risk of becoming alcoholic; if from alcoholic birth parents, 60%; if from non-alcoholic birth parents, 30%

Abstinence until 21

 A child who reaches age 21 without smoking, using illegal drugs or abusing alcohol is almost certain never to do so.

"A drug-free future begins here," CASA 2001 Annual Report

Risk/Protective Factors

 Risk factors include availability of drugs, family history of substance abuse, learning disabilities and other academic difficulties and peers who use.

 Protective factors include a supportive, involved family which practices abstinence. One supportive adult can make a difference.

Kids with addicted parents

 12% children live with at least one parent w/ substance abuse  7.3 million kids with alcohol abusing folks  2.1 million kids with drug abusing folks “Many U.S. Kids Have Addicted Parents, SAMNSA Says,” Join Together Online 5-5-09

CHILDREN OF ALCOHOLICS

 Alcoholism affects the entire family  Many people are exposed to alcoholism in their families  There is strong, scientific evidence that alcoholism tends to run in families. Children of alcoholics are more at risk for alcoholism and other drug abuse than children on non alcoholics.

COA’s Cont.

 Alcoholism usually has strong negative effects on marital relationships  Alcohol is associated with a substantial proportion of human, violence and perpetrators are often under the influence of alcohol  There is a strong relationship between parental alcoholism and child abuse

COA’s Cont.

 COAs exhibit depression and anxiety more than non-COAs  COAs score lower on tests measuring verbal ability  COAs often have difficulties in school

COAs, cont.

 COAs have difficulty with abstraction and conceptual reasoning  COAs can benefit from protective factors such as developing a close bond with a caregiver  Consistency of family activities can be a protective factor

  2.5 million children in the U.S. are being raised by grandparents or other relatives Family care has increased by more than 86%

“Mindy”

•17 years old •Thinks baby will solve all her problems •Smokes cigarettes and marijuana •Drinks a couple 40s per week •She’s is worried about harming the baby •How can you help her? What do you say? Is it too late? What can she expect?

The most important factor in assuring a healthy birth outcome for an addicted, pregnant woman is: Prenatal care

Rank the following substances in terms of the number of fetuses effected: Crack cocaine, Tobacco, Alcohol 1.Tobacco

2. Alcohol 3. Crack cocaine

Science…

 …must outweigh stigma, prejudice, and misunderstanding.  Addiction is not so much a failure of will as a failure of brain chemistry.

Cocaine-

Exposed Children

 Trained research assistants, unaware of a child’s history, cannot tell the difference between a 4-year-old who was exposed to cocaine before birth and one who was not.

Children, cont.

 Most maladaptive behavior and developmental delay in children from urban and impoverished areas is not uniquely due to prenatal cocaine exposure. Conversely, prenatal exposure does not necessarily lead to developmental delay or behavioral problems.

Children, cont.

 Stigma itself is a social and developmental risk to children who were cocaine-exposed prenatally, regardless of the pharmacological effects of the drug or the reasons for assuming cocaine exposure.

Children, cont.

 Labeling children as cocaine-exposed may lead to the imposition of negative expectations, which in turn undermines the children’s cognitive and behavioral development.

  How to Correct for Exposure?

The quality of the care giving environment was the strongest independent predictor of outcomes Cocaine-exposed children placed in homes with a stimulating environment and with caregivers with good vocabulary scores attained full-scale and performance IQ scores

Singer, et al., “Cognitive Outcomes of Preschool Children with Prenatal Cocaine Exposure,” 291:20 Journal of the American Medical Association (JAMA) (May 26, 2004)

FALSE

Babies born of mothers who use drugs during pregnancy are born “addicted.” Addiction required a fully developed nervous system. Not all babies are susceptible. There is no hard evidence that such babies seek drugs or lose control over drugs. Brick, J. and Erickson C.K., Drugs, The Brain, and Behavior: The Pharmacology of Abuse and Dependence. The Hayworth Press, Binghamton, N.Y, (1999)

CPS Issues for Using Parents

  70% of child abuse/neglect cases are based on AOD abuse Children in alcohol abusing families are almost 4 times more likely to be victims of maltreatment

Fetal Alcohol Spectrum Disorder



Alcohol use by pregnant/recent mothers: 2002-2007

11.6% pregnant women drink  16% teen pregnant girls drink consuming an average of 4 drinks over 6 days during the past month  42.1% recent mothers drink  54% all women drink

“

Alcohol Use among Pregnant Women and Recent Mothers: 2002-2007

,” The NSDUH Report (Sept. 11, 2008)

FAS/FASD

 4 million pregnancies in US annually   40% women drink while pregnant 3 5% drink “heavily” (5 drinks/day)   FAS birth rate from heavy drinkers = 6% FASD rate 0.97% - 9.1%/ 1,000  80% of FAS exposed to other drugs  Floyd, R.L. & Dishu, J.S. (2004) “Monitoring prenatal alcohol exposure,”

Am. J. Medical Genetics 127C, 3-9;

Abel, E.L

.

(1998)

Fetal Alcohol Abuse Syndrome

Plenum Press, NY NY

Mothers of FAS Children

 80 % had major mental illness    100% sexually, physically or emotionally abused 80% lived with men who did not want them to stop drinking 60% with phobias, most common agoraphobia, so they are unable to seek help outside their home

Role of Genetics

 Genetics may influence whether or not a child exposed to alcohol in-utero is born with birth defects  Mouse models 

Alcoholism: Clinical and Experimental Research

, April 21, 2009

Alcohol

 “We know that substance use by pregnant women is a leading cause of mental, physical and psychological problems in infants and children.”  Charles G. Currie, former SAMHSA Administrator

Substance Abuse is a Family Disease 

Mothers’ substance use/abuse may have lifelong effects on children

But Treatment Works

 CSAT study showed 2:3 women not using AOD after tx  86% of mothers had their children  fewer than 10% were involved with criminal justice  Women are more likely to initiate tx and remain drug free after tx Green, Carla A., Ph.D., M.P.H., “Gender and Use of Substance Abuse Treatment Services,”

Alcohol Research & Health

29:1 2006



Girls in the Juvenile Justice System





Barriers to Tx for Girls in the Juvenile Justice System

The Violent Crime Index arrest rate for girls rose 103% between 1981-1997 vs. 27% for boys.  The biggest increase was for

drug abuse

and curfew violations

Intergenerational incarceration

 Family stressors include poverty, death, and an intergenerational pattern of arrest/incarceration. 

54%

of girls have mothers who have been arrested/incarcerated

Lack of stability



95%

of girls in the Juvenile Justice system lack a stable home environment 

91%

have been suspended, expelled or repeated one or more grades.

Education

 School is described as a “battleground” with sexual harassment, racism, interpersonal rivalries with peers and inattention from adults.  Dropping out is seen as a necessary means of escape.

Mental health issues



88%

experience serious health problems; 

53%

need psychological services. 

21%

have been hospitalized in a psychiatric facility

Mental health issues



88%

experience serious health problems; 

53%

need psychological services. 

21%

have been hospitalized in a psychiatric facility

Victimization

• Girls’ and women’s pathways to offending is victimization. 

92%

of juvenile female offenders report some form of emotional, physical or sexual abuse.

Violence

 Girls age 13-14 are most likely to be beaten, stabbed, shot or raped.



25%

report being shot or stabbed one or more times 

11%

of girls witnessed or experienced the death of one or both parents or a sibling

Pregnancy



29%

of girls had been pregnant one or more times;  

16%

had been pregnant while in custody

Gangs/Young Women of Color



47%

report gang affiliation 

2/3

of the girls are of color, primarily African American and Latina

Girls underserved

 “

Girls in and on the edge of the juvenile justice system represent one of the least served juvenile justice populations. “

“Investing in Girls: A 21 st Century Strategy,” VI JUVENILE JUSTICE JOURNAL 3 NCJ 178254 (Oct. 1999)

Barriers to Tx for women

 What to do with the children?

 Who will pay for tx?

 Shame  Denial

BARRIERS TO TREATMENT FOR WOMEN WITH CHILDREN 

STIGMA, particularly for drug-using mothers

Former First Lady Betty Ford

“As a recovering woman, I have personally suffered the scorn of others who are confused, bitter and misled about addiction. …[H]ow could a nice person like me be an alcoholic?”

Lack of child care

 An average of 8% treatment facilities offer child care. When women can take their children to treatment, there is improved retention and treatment success  Loss of income and inability to pay for treatment

Fear of losing custody

 More than half (58%) of AOD directors and CPS directors said in 1995 a positive drug test is grounds for reporting a pregnant woman to a state agency compared to 12% in 1992

Fear of prosecution

 Fewer than ½ (45%) of state AOD and CPS directors reported criminal prosecution of drug using women in 1992 in their state compared to 71% by 1995

Suppression of violence

 Suppression of violence including rape, incest and domestic violence can trigger relapse and is a critical issue that must be addressed in treatment.  Recovery can be too painful for some women.

Programs offering women-specific programming  43.2% Methadone programs  41.7% Residential  35.4% Outpatient  46.9% Residential/Outpatient

Gender Specific Services:

“…those designed to meet the unique needs of female offenders, that value the female perspective, that celebrate and honor the female experience, that respect and take into account female development and that empower young women to reach their full potential.”

Girls, Inc.

1996

Women-only Tx  During tx, no significant differences  After 6 months, continuous reductions in use for those in women-only tx  Especially for alcohol tx  Women-focused and women-only have long term positive outcomes  Greenfield, et al., “The Women’s Recovery Group study: A Stage 1 trial of women-focused therapy for substance use disorders versus mixed gender group drug counseling,”

Drug and Alcohol Dependence

90:39-47, 2007

Resources:

 http://ncadistore.samhsa.gov/catalog/productDetails.as

px?ProductID=15498 

A Woman’s Way Through the Twelve Steps

Stephanie Covington by  Substance Abuse Treatment for Women Offenders: Guide to Promising Practices (TAP 23) CSAT Women for Sobriety, Inc.

http://www.womenforsobriety.org

A non-profit organization dedicated to helping women overcome alcoholism and other addictions

Resources

Resources

Resources

 Mental Health webliography  Co-Occurring webliography  Alcohol and Other Drug webliography  Women Specific Websites  Listserv  [email protected]