Parenting program for women and children in residential treatment

Parenting Program for Women and Children in Residential Treatment

Addiction is something that has been around for many years, and there have been increasingly new ways of treating it that have been created over the course of much research and study. There are many different forms that addiction takes, and there are many different drugs and substances that someone can become addicted to, even if they are not of the age that most people would think of when they picture people that would start down that particular road. Most individuals think of addicts as primarily young, minority men in their 20s and 30s that rob, steal, and cause other problems in order to get their drugs or alcohol. However, there are also many women that are addicted to various substances, and although race is a factor when looking at addiction numbers, there are plenty of people of all races and ethnic backgrounds that struggle with addiction and many of the problems that it can cause.

Addiction is unfortunate and painful in many ways for all that are involved in it, but nowhere is this more true than in the case of adolescents that become addicted to drugs or alcohol. Often this takes place because the parents also have problems with addiction, but sometimes it can come from other issues such as mental problems, family problems, a desire to be accepted, or simple curiosity that goes too far and causes an addiction to the substance that was experimented with. Whatever its cause, addiction is a problem that is not often corrected without some kind of treatment or intervention. Not all people that become addicted to something require help to correct their path in life, but many do and they are the ones that desperately need some kind of help before their addiction steals their whole life from them.

It is not only upsetting to those that struggle with addiction but it causes turmoil and problems with other family members and relationships as well. Those that care for these people see the problems that they are encountering and sometimes they are not sure how to help these people and make them better. Often, drastic intervention in the form of arrest and sentencing is the only thing that will make these people turn their lives around, and sometimes not even those things are enough.

Where parents are concerned, there is a better chance of curing them. They often do not want to lose their children or want to get them back if they have already lost them, and this gives them more of a reason to try to stay clean. Most of these parents are young, and because of this they have not been a slave to their addictions for as long of a time period as most of those people that are older and they often really want help, even if they say that they do not. Some will go into treatment on a voluntary basis and others will have to be forced into treatment through the court system. Whether these individuals complete their treatment and whether they remain clean once they leave treatment are significant issues in both the voluntary and the forced admissions, and they are part of the discussion in Chapter Two, where the literature is reviewed.

Even when court appointed admissions are what bring parents into treatment some of them do not complete it. These individuals sometimes leave their treatment plans and do not return. The dropout rate for these individuals must be compared to the drop out rate for those that admit themselves voluntarily to treatment programs for drug and alcohol addiction so that it can be determined whether there are significant differences in the interest in completing a program when it is entered voluntarily vs. being forced to enter it through the court system. This is not the only important issue here, but it is one of the important issues if a parenting program that deals with recovery from addiction is going to work for the majority of people that enter it. Statement of the Problem The issue of parenting when it comes to drug dependency and other issues is one that has been misunderstood for many years. There are individuals that study it and discuss how significant it is, and there are others that see it as some kind of made-up problem that is really not important enough to focus on. Both of these are valid points-of-view but, in recent years, it has generally been accepted that children that have parents with drug or alcohol problems needing treatment is a significant issue, and that the study of it is important. Unlike standard medical problems, such as diseases that affect the body, this kind of behavior is not something that can be medically 'cured,' as it is understood in the traditional sense.

However, there are treatments available for parents and children and there are many different thoughts and theories as to what causes these problems in some people and not others, and how it should be handled when it does occur so that the patient can get the maximum amount of benefit from the treatment or treatments that are offered to him or her. For a study such as this one, it is important to discuss these treatments, but it is also important to look at how the problems that parents and children face with this issue affect the country's families and what kind of prevalence is noted with symptoms of this disorder.

While this particular study deals with the parenting experience of substance abuse and treatment, it is important to remember that parents are not the only ones that are affected by it. There are others that have been through very traumatic situations where dependency is concerned and are also strongly affected by these situations in the days, weeks, and months that follow. Without a proper understanding of the issue, and without knowing that help is available to them, they will continue to suffer and remain silent about their problems, or not understand what is happening to them. Some people do not like to see any doctor that is associated with mental health or drug/alcohol treatment because of the stigma that comes with it, but this is not as significant as it used to be, and many substance abuse issues are being seen and respected as legitimate difficulties that need treatment.

This problem can be difficult for those that are parents, however, because many of them have a slightly different mentality than the average person in that they seem to feel as though they should be able to deal with whatever comes their way without outside help, especially from the mental health or substance abuse field. In short, they often feel that having these kinds of problems equals weakness, and only those that are weak and not in control of themselves need the services of someone in this field. The stigma is still there for many of these individuals, and it can prevent them from seeking treatment, even if they know that they have some difficulties that are not being resolved on their own.

Children whose mothers are addicted to drugs and alcohol are at developmental risk. This risk can be both biologically based, as when the child was exposed to substances prenatally, and environmentally based, as when the home environment provided by a substance-abusing parent is disorganized, even chaotic. Furthermore, the risk is compounded by the fact that most mothers who are addicted are unavailable to their children, both physically and emotionally. When they enter the recovery process, the goals focus on recovery in terms of abstention from using, and overlook the repair of the child's home environment and relationship with the child. The purpose of this project is to develop a basic childcare curriculum for mothers who are in recovery from drug and alcohol addiction, with the goal of repairing the relationship with the child. This repair will not only help the child, but also help prevent future relapse by buffering the mother from seeing the child as a source of stress. Purpose of the Project The purpose of this project is to create a curriculum that is most effective with the population of women, who are recovering from alcohol and drug addiction, and their children, who are all living in a residential treatment facility. Another purpose of this project and the study that comes before it is to not only show the seriousness of the problem in question, but to come up with ideas that will help to show how this problem can be reduced in size. Because children and adolescents are such an important part of the country and because the population is growing so rapidly, this is one issue that demands immediate attention and action. The best way to do this is to first analyze the problem in question to determine just how serious it actually is, and then use that seriousness as a wake-up call for those that have been looking the other way and avoiding dealing with the issue. There are many of these individuals, and it is time that this is changed.

Parents often look away from these kinds of problems, or they spend their time in denial of the issue because they feel that their child will not be harmed by parental involvement with drugs or alcohol. Some parents have parents that were/are addicts themselves, and some are so busy with their lives that they do not actually realize that their child has any kind of problem with the lifestyle of the parent until it becomes so severe that it cannot be overlooked, or until it is brought to their attention by police, the school, or someone else that has seen it first hand. Parents are not the only ones that overlook this issue, though.

Sometimes siblings and friends also see problems that they ignore, do not understand, or do not talk to anyone about, and the school system cannot watch every child every second that they are in attendance. Children that have parents that are substance abusers are much more likely to abuse drugs or alcohol themselves, especially as they reach their teenage years, and therefore changing the actions of the parents is one way to slow the growth of substance abusers in this country and help a future generation avoid these problems.

Teachers have busy class loads, and unless there is a marked and obvious change in the behavior of a student, it will often go unnoticed by teachers and others in the school system. Usually, the problem comes to light when the adolescent has some severe problem such as would involve police, a suicide attempt, or other cry for help that simply cannot be ignored. This is not the first sign of a problem with drug or alcohol addiction, but it is often the first one that parents and others notice. Even if the adolescent is not abusing drugs or alcohol, this cry for help may come from being overwhelmed by the home environment and what is taking place there where substance abuse is concerned.

The children in this country are the future, and they must be taken care of and protected as much as possible. This is often difficult to do, and there are so many potential problems when one is young, but where treatment for addiction is concerned, the completion of this treatment and the reasons behind their admission are ways to help protect these individuals from the damage that their parents are doing. These parents, particularly the youngest ones, are in many ways still children, and they must learn how to protect themselves and their children from some of the dangers that they face as they grow up and explore their world.

All studies must have a strong purpose, and this one affects one of the nation's most precious resources - children. Even though these children likely see themselves as adults or nearly adults, they are really still children. They have often had to grow up very fast and take care of themselves because of their parents' addiction, and some of the children that were exposed to drugs and alcohol while still in the womb have developmental problems that they are fighting to overcome. They are still growing and changing their beliefs and their sense of self. Because of this, they need more protection from themselves and from others than they actually think they do, and the idea of making sure that their parents get treatment is one way to do this for them. It helps to protect them from the impulses and desires that their parents have, and it helps to protect others from those same things. It also helps to protect the children from others that might be unscrupulous enough to con them into some idea that would be dangerous, such as getting involved with the same kinds of addictive behaviors that their parents are involved in or moving on from the drugs that they may consider using to those that are more addictive and dangerous.

It should be understood that there is no way to completely children from doing dangerous things, and there are also plenty of adults that will do the same thing. The issue is, however, that adults often get away with difficult or dangerous things because they are more skilled at them and even though they still should be avoided, an adult that has been performing this kind of behavior for some time has more ability to predict how likely they are to continue to get away with this behavior. The key is to stop these parents from engaging in this type of behavior to protect their children, and to show them why they are headed down the incorrect road and the damage that it could be doing to others.

Significance of the Project

It is necessary and pertinent to discuss the significance of a study, and this particular study is important to many people across the country. Since children and teenagers are the future of this country and will be running it when they get older, they must be protected. It is not always easy to protect them because they often feel as though they do not need it - especially when they get into their middle and late teenage years. When they see the kinds of behaviors that their parents are involved in, they begin to view these behaviors as acceptable. Often at a young age they begin to feel as though they are capable of making their own decisions and taking care of themselves. This assumption is broadly true, since they are able to do many things that they will need to do later in life without assistance, but they must understand when their parents make poor choices, and the parents must also understand how to take care of their children properly and the damage that they are doing to themselves and their children by becoming involved with drugs and alcohol.

Many adolescents get involved with drugs and alcohol because of peer pressure, and while campaigns that teach them from a young age to 'just say no' are proving to be fairly effective, they do not work for all children, or there would be no adolescent addiction issue to discuss. Because it has been seen that these kinds of campaigns are not preventing adolescents from using drugs and alcohol, something must be done that will work better. Baring this, treatment programs for these individuals must be more effective, so that fewer adolescents that complete these programs will go back to using drugs and alcohol when they are released from treatment.

Ways to make these treatment programs more effective are not the focus of this study, but they are certainly worthy of future consideration in other research. Most important for this study is to determine what needs to be done for the parents of these adolescents and younger children, so that the addictive behaviors that the parent has will be stopped and will not project themselves onto the child. It appears that there is a strong likelihood that allowing parents to have their children with them during recovery will help stop these parents from relapsing and will teach them much more about the needs of their children. If this does in fact turn out to be the case then the reasons behind this should be determined. There may be many ways to increase the chances of those parents that are ordered to go through treatment, and there may be ways to make parents that would normally be ordered to go to treatment feel as though they want to attend it. Making it seem voluntary to them and allowing them to have their children with them during the recovery process may make all of the difference. This study will seek to show whether that assumption is accurate. If it is, it will open the door to future research and speculation on the issue.

The significance of this project involves incorporating the mother and child in the recovery process to help reduce the chance of relapse. If a more functional and loving relationship can be established then the mother is less likely to relapse back into an active addiction lifestyle. This is an important issue because Baker (2000 p. 870) found that most residential treatment facilities do not allow children or offer childcare services. If children are not permitted and childcare services are not offered, how do these women and their children begin to work on the recovery process of repairing their relationship?

Having worked in the recovery field for six years at a residential facility which does allow children and provides childcare services, I have found a need for such a curriculum. Working with mothers in recovery, I have seen that many are unaware of the effects of prenatal exposure and chaotic home environments on their children's development, and have no clear understanding on how to help their children. The goal of this project is to incorporate the mother and the child in the recovery process to help reduce the chance of relapse. If a more functional and loving relationship can be established then the mother is less likely to see the child as an uncontrollable source of frustration.

The scope of this particular study is very broad and far-reaching, because there are so many people that are being affected by it now and will be affected by it in the future. When studies reach far and effect many people they take on more general significance and importance than they would if their scope was very narrow. This is not to imply that studies with a smaller scope are not important, but only that they usually do not affect as many individuals across the country or across the world.

This study, however, has the potential to affect almost everyone. All of those parents that are receiving or need to receive treatment for drug or alcohol addiction could be affected, as well as all of those that know them. This includes not only their families, but their friends and others as well. Even those that do not know any parent that has these kinds of problems could still be affected, as parents and others that are addicted to drugs or alcohol sometimes commit crimes and cause other problems. These things would be lessened if treatment options were better and if fewer parents went back to their old ways of doing things when they were released from treatment. Their children would also greatly benefit from having parents that are clean and sober, and this would lessen the chances that the child or children would take a path that would involve drugs and/or alcohol.

Other researchers that are interested in this idea or ideas similar to it could also be affected by this study. It may provide them with new insight into the problem, or may give them ideas as to how they wish to study something in the future or what angle they want to pursue when looking at a specific problem. In turn, these studies that these other researchers will conduct may further advance the field of study into this issue and may help even more individuals through an understanding of what works and what does not when it comes to treating parents for addiction.

Studies such as this one, that reach a long way out into society, are often examined rather thoroughly by others that are interested in the same field. Part of this is to pick up new and important information about the issue, but part of it is also to determine whether there are weaknesses in a particular study that can discount the information that is collected. In order to avoid this, since this study has such a wide scope, the limitations and other potential problems will be considered and discussed during this chapter. It is necessary to do this because of the potential discounting of the study in the future if this is not done, and also to show that the researcher understands fully what he or she is doing with the study and what any potential problems may be.

Limitations

As with any study, this one has some limitations that must be dealt with. All studies have their problems and limitations that surface, and tackling them and discussing them do not indicate weakness, but rather they show the strength of understanding possessed by the researcher when looking at the chosen field for the study. It is with this in mind that the limitations of the study will be discussed here, so that it can be shown that the researcher had a full and complete understanding of the problems inherent in doing a study such as this with the resources that are available. Any biases that the researcher might have can also be considered a limitation.

Limitations to a study are often overlooked by the researcher, but this can pose problems for others that wish to use the research at a later date. Unfortunately, this happens quite often, and it makes research suspect when there are no limitations discussed. In an effort to avoid this, all limitations of this study that are recognized by the researcher will be clearly spelled out and discussed so that there is no concern in the future about whether the researcher knew what kinds of problems might arise or what should be done about them if they did. In this way, any issues that could come up and be problematic will be avoided and the information contained in the study can be accepted as being reliable, valid, and unique.

As has been mentioned, limitations are too often overlooked in studies, and it is often impossible to find all of the limitations that are contained in a study and spell them out for all to see. However, that does not mean that the limitations that are noticed should be overlooked. As long as they are legitimate, the more limitations that are discussed in the research the more significant the research will be found to be, since any weaknesses that it might have will be noted and dealt with. It is for this reason that this particular section will detail the limitations that this study faces.

By detailing them and discussing them instead of simply listing them, the reader can develop a stronger understanding of what the researcher was really trying to accomplish and what kinds of things might get in that researcher's way while at work. This is important and will allow for greater freedom of expression throughout the study. It also ensures that any concerns that others may have about the research have been dealt with and therefore cease to be problematic.

The first limitation that is important to note is that there is so little information about the case study subject in question - treatment programs for substance-abusing parents that allow the children to be present during recovery. While there is indeed some information, much of it comes from studies that deal only with treatment programs for drug and alcohol addiction and not with the parenting issue specifically. Therefore it is not as thorough as it could be if it came from sources that dealt with parenting and having children present during treatment. It is necessary to discuss this somewhat to show exactly where the problem lies. If there were journal articles and other research written about parenting and treatment programs, much of it would be objective, with some subjectivity on the part of the researcher undoubtedly thrown in. Without this, however, the only information that can be located in general is information that deals only with treatment programs in general and therefore does not give the strong parenting component to the research that this particular study needs.

With that in mind it is important to note where the information that is being collected for the study of this issue is coming from. There is no reason not to use the information that is provided by others, but making sure that one is aware of where it comes from and what potential consequences that could have is of utmost importance when it comes to looking at the limitations that can be found in research. Making sure that the most accurate data available is used is significant and when something cannot be verified it should be pointed out in the study that it cannot be verified so that there is no further confusion as to whether that piece of information is legitimate or not.

It is disturbing that there is such a small amount of information that is available on the issue at hand, specifically when it comes to parenting. There is information out there, but finding good quality, legitimate information from a proper source is somewhat difficult. While this is not terribly significant for the literature review or most other parts of the study, it is significant for the conclusions that are drawn and the parenting program that is being created, because the information that has been collected by the researcher needs to be backed up, if possible, by information that has been discovered and studied by others. With this is mind, it is troubling that there is so little information presented on this particular issue and its significance to the treatment of parents with drug or alcohol addiction.

While upsetting, however, this does not mean that the study cannot be conducted and perform all that it is expected to do. Care will have to be taken when discussing the issue of drug and alcohol treatment programs where parenting and children are concerned in Chapter Four so that there is an understanding about whether the information collected is subjective or objective. When this is established and understood the lack of information, or lack of information from sources that the researcher is comfortable with, will cease to be a problem any longer, and the research study can proceed, secure in the knowledge that all limitations have been dealt with and everything that could affect the study has been disclosed correctly.

This should be true of both positive and negative effects, as both are significant when it comes to studies such as this one. Even something that can have a strong positive effect on a study should be discussed because it may affect the findings to a certain degree, and this would affect the end result of the study. By discussing this limitation beforehand, there is little chance that the research will be seen as insignificant in the future due to a lack of disclosure about possible problems with the study and possible issues that could come up with regards to limitations.

Another limitation of the study that must be discussed in some detail is the fact that what causes someone to turn to drugs and alcohol and the problems that it causes is somewhat hard to understand for those that have not been involved with it in some way. The terms and symptoms, in and of themselves, are not confusing, but explaining what they actually mean and how they are measured can be somewhat difficult for many. Obviously, this has a great deal of significance, since being able to define something makes it more 'real' somehow, and lends itself better to an actual study of the issue.

When something cannot be measured on any kind of official scale, it makes the study of it that much harder and that much more suspect. Since this is the case with drug and alcohol dependence in parents and the problems that it creates for children to some degree, limitations of this nature should be thoroughly discussed to ensure that they do not cause problems in the study, and to be sure that they are thoroughly understood by all who read the study and potentially use the research in the future for their own studies.

Reminding oneself of what the terms mean in a particular study can greatly help where limitations are concerned, because certain terms are utilized differently depending on the study conducted and the understanding of the researcher. It is important to point this out, however, because a failure to do so could lead to misinterpretation of the data presented and the way that it is described, which could cause the study to be discounted and treated as though it has no significant information to impart to others who might be considering using some of its research for their own studies in the future. Making sure that the terms are clearly stated and explained will help to avoid this problem.

Another limitation of this study is that the study is largely subjective. Some may not see this as a limitation, but other will view it that way, and so it is important to discuss it and clear up any concerns early on. Objective studies are analytical and deal with facts and figures. Subjective studies deal more with perceptions and feelings, as well as thoughts and beliefs. While both are good ways of studying things, the kind of study that is being performed often dictates which way the study is conducted.

For this particular study, being able to be objective and provide facts and figures about parenting and treatment programs would have been good, and could have provided some very significant data that would be important for future study. However, when dealing with issues such as this where there is little information already created about it and it has not really been strongly studied, there are few facts and figures that can be used and relied on with any degree of certainty. This is why the study is subjective - not because there are no figures provided, but because the figures provided are based on answers to Yes/No types of questions, and these types of answers are largely subjective and based on the perceptions of the individual answering the question or performing the study. As has been mentioned, not all will see this as a limitation or a weakness of the study, but it is mentioned here so those that do view it that way will be aware of it.

The main limitations to the curriculum that will be created, however, are in the realm of length of stay and attrition in general. Many of the women who enter our program vary their length of stay from one month to six months. The longer a woman stays in treatment the longer she is able to benefit from this curriculum. The other issue is attrition. "It is important to keep in mind the frequently high dropout rate experienced in long-term, residential treatment programs. It is not unusual that between 30% and 50% of those who begin treatment drop out before completing treatment" (Moore & Finkelstein 2001 p. 228).

Organization of the Project study of this length and magnitude needs an overview so that the reader can be provided with a sort of road map that makes them aware of exactly what will be involved in the study. This first chapter detailed some of the basic information that will be dealt with in the rest of the study, including the statement of the problem and the reasons behind why the study was conducted. These are all very important issues to discuss, as they set the stage for what will come later.

In Chapter Two, the literature on this subject will be reviewed. The literature review chapter will be very extensive, as there is a lot of literature that has been written about substance abuse and treatment and there are many theories that deal with it in some way. These theoretical ideas are very important because they help with an understanding of what the addiction and the beliefs surrounding it stemmed from. Without an extensive literature review, it would be more difficult to understand some of the ideas behind the study and some of the reasoning behind the conclusions and recommendations that will be provided. The most important thing, however, is the idea that the literature review must be complete and thorough in order to ensure a solid understanding of the rest of the chapters.

Chapter Three will deal with the methodology for the study, and will explain exactly what will be studied and how it will be studied so that the conclusions in Chapter Four will be clear. Chapter Three will also be somewhat lengthy, as it is important to ensure that the type of analysis being done is clear and that all concerns, validity issues, and other possible considerations are studied and defined. Without this explanation, there could be questions later regarding what was done in the study and whether it was actually valid and reliable in what conclusions were reached and what was suggested for the future.

Chapter Four will summarize the entire study and discuss the information that was provided in it. Also in that chapter will be the conclusions that were reached by the researcher and the recommendations that the researcher made toward future research into the issue. This is also very important, because every study has some limitations that must be dealt with and leaves possibilities for other researchers in the future. These possibilities should be pointed out so that research that is done in the future can take the proper direction and provide the most beneficial information where the issue of addiction and parenting is concerned.

The organization of the project (see Appendix) is all encompassing for the client in residential treatment. Understanding the lifestyle of addiction and what it means to be in recovery are addressed. This lays the groundwork for understanding the lifestyle in which the child is coming from. This allows one to identify the specific areas that match up with this child's needs. Incorporating these needs into the childcare curriculum allows this child an opportunity at improved behavior and the mother an increased opportunity at successful recovery. Creating a childcare environment, which is conducive to these children's needs, is important to this curriculum.

The curriculum will be two fold: first, basic childcare lessons will include education for the mothers on both the effects of biological and environmental facets of addiction, and basic parenting tools. Second, in context of a structured childcare facility, the children will receive a nurturing and consistent childcare environment. In order to develop this curriculum, I will explore the following: if there were specific needs of children who were prenatally exposed to alcohol or drugs, or have lived in chaotic home environments which may have been caused by addiction.

The Theoretical Basis of the Project

The theoretical basis of this project will focus on Erik H. Erikson and his first three stages of child development. Erikson believed that successful completion of each stage was needed before being able to successfully complete the next stage. These stages are building blocks for later stages. Erikson has eight stages in all, however the first three are most pertinent to this project, because the age of the children in the residential treatment facility. The first stage is Trust vs. Mistrust and it is the age from birth to one year of age. The second stage is Autonomy vs. Doubt and this is from one year to two years of age. The third stage is Initiative vs. Guilt and this is from age two to six years of age.

Based on the addiction lifestyle and how children are raised within it, there may be a correlation between Erikson's stages and the behavior of these children. By creating the curriculum around the positive aspects of Erikson's stages one can help the child to the stage they should be at. "If the childhood crises are not handled satisfactorily, the person continues to fight his early battles later in life. Erikson optimistically claimed that it is never too late to resolve any of the crises" (Miller 1993 p.159).

Other information that will help to reinforce the theoretical basis of the study will come from the work of Dr. Ira Chasnoff and the social model theory created by Bandura. These are both significant in looking into the issue at hand and they will help to make more sense of the issue and the reasons that the researcher has for creating the curriculum in this way. Without a clear understanding of the theory behind the work that the researcher is doing, there will be little that the researcher can do to show that the curriculum that is being proposed will work well for parents and their children.

Even though it is possible that some people will see the significance of the issue without an understanding of the theory behind it, the theory reinforces the most important points of the issue and therefore helps to show others why there is so much significance to this kind of study and why many individuals must understand that the treatment programs that allow children to be present during recovery help the children and the parents to create a stronger bond and therefore help to prevent the parent from relapsing into the drug and alcohol behavior that they were previously involved in.

Chapter Two

Review of Related Literature

The literature review is an important aspect of any study as it provides insight and background into the subject at hand and provides a lot of information that can be later utilized in an analysis of the data. For this type of subject in this particular literature review articles are utilized that will provide information into substance abuse and parents and the type of treatment that many of them receive. For ease of understanding and providing information for this literature review these articles will run consecutively as opposed to utilizing information concurrently from various sources.

One of the most important issues that need to be understood first is that there are many adolescents that end up in drug or other substance abuse treatment. This is significant for two reasons. First, many of these adolescents come from homes where they have seen their parents abuse drugs and alcohol, so breaking that chain early is important. Second, these adolescents that are having drug and alcohol problems will grow up and become parents. If they do not break their addiction first, they will harm their children and send many of those same children down the path that they are traveling. While adolescents are not the group that the parenting program (see Appendix) is being designed for, what is happening to them is still very significant, as it points to the future of drug and alcohol problems within this country.

A report from September of last year indicated that there was an increase in 2002 for treatment for substance abuse in those in the 12 to 17-year-old age group (Drug, 2004). According to many officials in the government that continues to show a trend that has been evolving for over a decade (Drug, 2004). Between the years of 1992 and 2002 those in the 12 to 17-year-old age bracket that were admitted to any type of treatment program for substance abuse increased approximately 50% (Drug, 2004).

In 1992 those in the adolescent category represented only 6% of all of the admissions to treatment programs (Drug, 2004). But the year 2002 they represented a total of 9% of those admitted for treatment to substance abuse programs (Drug, 2004). Most of this was believed to be due to a strong rise in the number of adolescent admissions for abuse of marijuana (Drug, 2004). In between 1992 and 2002 those who were admitted to adolescent treatment programs primarily for abuse of marijuana rose over 350% (Drug, 2004). One-quarter of adolescent admissions to treatment programs in 1992 were primarily for the abuse of marijuana (Drug, 2004).

In 2002 admissions of adolescents to these types of treatment programs for marijuana abuse was 63% (Drug, 2004). The study indicated that getting the message out to adolescents regarding the dangers and addictiveness of marijuana was something that individuals in this country must work harder at (Drug, 2004). Those who use drugs and the drug use itself must be confronted in this country in a direct an honest manner in order to help discourage adolescents from using drugs and also to provide adolescents who do have drug problems the opportunity to enter treatment and to remain in that treatment through completion instead of dropping out. In 2002 approximately half of the adolescents that were admitted to treatment centers for substance abuse were involved in both marijuana and alcohol abuse (Drug, 2004). Admissions that involved this double problem increased approximately 86% between 1992 and 2002 (Drug, 2004).

Studies that have been done in recent years on adolescents in the 13 to 18-year-old age groups indicate that between 7 and 17% of them meet the criteria for either substance dependence or substance abuse (Kaminer, 2000). Some of these older adolescents are also already parents, having made other bad choices in their lives that often stem from an abuse of drugs and alcohol. The research on adolescent treatment and the outcomes that these adolescents have when looking at substance abuse disorders is far behind the research that has been done on adults. There are methodological problems and many differences that are significant and which help to complicate the interpretations that are made of many of the results in the small body of literature that is available on the subject (Kaminer, 2000).

Some of these differences and complications include selection criteria that are different from those of adult studies, small sample sizes, a lack of objective measurement of whether the treatment outcome was actually successful, and very limited or no follow-up studies which would provide more information. Treatment strategies that are psychosocial in nature, such as cognitive behavioral, behavioral, motivational interviewing, and family therapy techniques have often shown that they help to reduce not only the substance abuse but other related problems that are often seen among adolescents (Kaminer, 2000).

The family therapy technique may also be seen as significant for the parents of these adolescents (and younger children as well) that struggle with drug and alcohol abuse.

However, despite all of these notable comments and information that has been learned over recent years there is still no specific treatment approach for adolescent substance abusers that clearly shows as superior. This can also be considered to be true of older adults and parents, although indications are that allowing children to be present throughout the recovery process may prevent a relapse. Adolescents must be helped, but the parents of these adolescents must also be helped, and this can be difficult for those that do not wish to seek treatment or for those that do not believe that treatment is necessary.

There are two important and relatively significant difficulties that generally dominate when the treatment of these individuals is examined (Kaminer, 2000). The first one of these is a lack of motivation that many of these individuals have to enter the treatment arena and remain in it until treatment has been completed (Kaminer, 2000). The retention rates are therefore very low to moderate and the dropout rates are exceedingly high (Kaminer, 2000). Second, most of the studies the deal with substance abuse and treatment rely on strictly objective measurement in order to help assess how well the treatment outcome actually appears (Kaminer, 2000).

Supervising drug screening through urinalysis in order to give a more objective outcome is often either partially reported or not reported at all and therefore the likelihood of actually getting accurate information regarding treatment outcomes for substance abuse is extremely difficult (Kaminer, 2000). Addressing these problems is clearly necessary and adapting new interventions or developing more effective interventions for the research that has been done on adult substance abusers is clearly a desirable idea (Kaminer, 2000). This is very important for many of the outpatient services and ambulatory settings that are available because individuals generally receive outpatient type services for this type of treatment and only one third of people that are treated for substance abuse problems are considered to be inpatient (Kaminer, 2000).

Utilizing reinforcement procedures based on contingency management provide strong rewards for having clean urine screenings and this is one of the strategies that are being considered today as appropriate in order to determine how well treatment outcomes are actually doing (Kaminer, 2000). Achieving abstinence from drugs across the population, especially where parents are concerned, is a goal that has proved to be very elusive but it is possible that more success will be given to this by providing incentives that are based on showing evidence or proof of that abstinence (Kaminer, 2000).

Reinforcing this type of system and utilizing it in combination with a treatment program based on behavioral ideas has indicated that outcomes in this area may be very impressive when looking at substance abusers that are in the adult population (Kaminer, 2000). Also noteworthy is the fact that marijuana which is commonly used by adolescents and often dealt with in treatment programs in the 13 to 18-year-old age group responds very well to contingency management intervention (Kaminer, 2000). What works well for adolescents in this area also works well for adults. Unfortunately, even though there is a lot of evidence showing that these ideas and procedures are acceptable and are applicable to the issue at hand there is only one study done detailing these kinds of procedures with the adolescent population, so whether this is really working is questionable (Kaminer, 2000). This is part of the reason that parental drug use must be stopped, so that there will be a lower chance of children and adolescents choosing drug use.

Treatment based on contingency management details a conceptual framework that deals not only with behavioral pharmacology but with behavioral analysis as well (Kaminer, 2000). In a framework where using or abusing drugs is considered to be operant behavior, it is assumed to be easily maintained because there are many reinforcing effects of the drugs themselves (Kaminer, 2000). In contingency management there are several core strengths that are very important. These include conceptual clarity, operationism and empiricism, compatibility with many different types of pharmacotherapies, a large clinical breadth, and efficacy that is clearly demonstrable (Kaminer, 2000).

Strategies used in contingency management involve rearranging the environment for substance abusers so that abstaining from drugs or using them is easily detected through urinalysis, abstinence is strongly reinforced by rewards for those who provide clean urine specimens, the positive reinforcement that these individuals receive is immediately lost if the results show drug use, and how much reinforcement these individuals get from nondrug sources is increased very strongly to compete with many of the good and reinforcing affects that these individuals receive from the drugs that they use (Kaminer, 2000).

Obviously this is necessary to reduce or hopefully eliminate drug use among individuals as much as possible and some of the ways to help facilitate this are to comply with the treatment plan, attend the clinic, and change one's lifestyle or behavior so that abstinence from drugs or alcohol is more easily facilitated (Kaminer, 2000). Extensive reviews that have been done for some studies have indicated that contingency management procedures and treatment regimens show very strong acceptability to patients and that they are very feasible for the task at hand (Kaminer, 2000).

The acceptability of treatment is extremely important and this is particularly true in parents (Kaminer, 2000). Many of these individuals are not motivated for initiating or maintaining any type of treatment and it has been hypothesized that this is part of the reason that the dropout rate is so high (Kaminer, 2000). When these individuals are forced into treatment they are much less likely to have any kind of motivation to go through with the treatment and remain clean when the treatment is complete (Kaminer, 2000). By not forcing them into treatment and by allowing them to have their children present through recovery, there is a higher chance that these individuals will attend treatment and remain clean.

Contingency management appears to be very effective for helping to retain patients in the adolescent category that are already in treatment as well as getting other, older individuals into treatment if they need it (Kaminer, 2000). Many of these contingency management procedures are utilized in treatment programs for eight to 12 weeks (Kaminer, 2000). A variety of reinforcements can be used on these individuals and many of these are quite commonly used in many clinical settings for substance abusers (Kaminer, 2000). If they are not normally used in a particular clinic they are easily adaptable (Kaminer, 2000). The parenting program that is detailed in the Appendix is one way of adapting reinforcements to the standard clinical ideas of recovery from substance abuse.

Some of these reinforcements may include small amounts of money for providing clean urine specimens, movie passes, vouchers offering fast food, and other small retail items where adolescents are concerned (Kaminer, 2000). With adults, and especially with parents, the rewards should involve their children. It is important that these rewards are tangible and are seen to be something that is desirable to the population (Kaminer, 2000). There are some that oppose this type of procedure even if it works well because of the concerns that these patients will take what they are given for these clean urine samples and then begin their drug use again (Kaminer, 2000). If the parents that attend the parenting program can be shown how significant what they do is to their children, it is hoped that they will refrain from abusing drugs and alcohol in the future.

There are several specific tips that must be looked at in order to consider implementing a program of contingency management and those that are interested in this type of issue must be aware of the outcomes and the concerns (Kaminer, 2000). However, the information regarding how to create one of these types of contingency management reinforcement plans is not entirely relevant to the information needed for this study and therefore the tips will not be listed here (Kaminer, 2000).

Another important issue for substance abusers and the treatment that they often receive for substance abuse is to ensure that the personnel that are treating the substance abuse and the officials who deal with health in other areas of the abuser's life are in agreement about what should be done (Wood, 2002). There are literally thousands of individuals each year that participate in substance abuse treatment on a residential level (Wood, 2002). Many of these individuals complete treatment and then they return to their lives (Wood, 2002). This type of treatment for substance abuse can have a lasting effect on individuals and helping to ease them back into life and collaborate with other people in their life, including their children, is vitally important to assuring that they make a good adjustment and have as little chance of relapse as possible (Wood, 2002).

Abusing or using dangerous substances represents a very strong threat to personal health in this country today (Wood, 2002). Quite often individuals will eventually develop many problems from the use or abuse of substances and will therefore require various treatment services (Wood, 2002). Between the years of 1993 and 1998 datasets dealing with treatment for adolescents revealed that over 700,000 young people were involved in alcohol or drug treatment services of some kind (Wood, 2002). In 1998 alone, over 100,000 adolescents participated in either outpatient or residential substance abuse treatment programs within the United States (Wood, 2002).

Throughout history adolescent drug or alcohol treatment programs have usually been based on or modeled after treatment programs that were created for adults (Wood, 2002). This made sense at the time but as more studies are done into this issue it is seen that adolescents that abuse substances have differing needs from those of their adult counterparts (Wood, 2002). In order to be successful treatment for adolescents must address more things than just substance abuse (Wood, 2002). The personal and social skills that an individual has, the way that he or she controls anger, the way that an individual controls their impulses, and what type of sexual education these individuals have had are all factors (Wood, 2002). Even though these are seen to be different for adolescents than they are for adults, many adults that are parents today still do not have a basic understanding of many of these same issues, and the parenting program can help them reach these goals.

There are multiple problems that face substance abusers that are still very young when they become parents and by looking at integrating comprehensive services to include group therapy, vocational training, family therapy, education services, individual counseling, and drug education, these individuals can best be served (Wood, 2002). There is a wide range of treatment options that are available for substance abusers and they follow a continuum of care (Wood, 2002). This generally begins when individuals are referred for a type of treatment service at a residential level and this continuum follows through their discharge from the program and the return that they make to their 'real' lives (Wood, 2002).

There have been many drug and alcohol treatment programs in this country for many years but there has been very little research on a qualitative level this looked at the procedures and practices that these type of treatment programs involved (Wood, 2002). Observing and analyzing the processes and goals of substance abuse treatment, identifying opportunities that can be utilized by health personnel at jobs and in other areas of life in the substance abuse treatment process, and determining how those who work in health services can help support those individuals who are most at risk, and their families, are all important issues that must be dealt with (Wood, 2002).

Qualitative case study methods are important to examine because they provide a lot of insight into some of the thoughts and feelings that these individuals have as they go through treatment (Wood, 2002). One study looked at individuals that went through treatment at a youth program (Wood, 2002). Twenty-four young men were studied, ranging in age from 12 to 18 years old (Wood, 2002). These individuals had been referred for substance abuse services because they had alcohol and drug abuse problems (Wood, 2002). There were specific admission criteria that these individuals had to meet and these included being diagnosed with substance dependence or abuse, being between 12 and 18 years of age, and being willing to participate (Wood, 2002). In other words, these individuals, although referred for this treatment, were volunteers in a way because they were willing to go and participate in this drug treatment program (Wood, 2002).

Most of these young men were expected to stay at the treatment program between four and six months (Wood, 2002). The study wanted to examine what these individuals experienced as they went through their treatment and it utilized many different ways of determining how these individuals felt as they worked their way through the treatment process (Wood, 2002). One of the major things they were taught in treatment was to believe in themselves (Wood, 2002). Having knowledge of the treatment, self-control, and the support of their peers were also issues that they were asked to look at (Wood, 2002). Sobriety was the stated goal of the treatment program but the study indicated that helping these individuals to believe in themselves once again appeared to be the primary goal (Wood, 2002). This should be a goal for any treatment program, no matter what the age of the participants, and can be particularly important for parents, since they must believe in themselves and their abilities before their children can really believe in them.

The treatment knowledge, peer support, and self-control previously mentioned were ways that this goal was accomplished (Wood, 2002). By going through the treatment process willingly these individuals found themselves having a different outlook on life than they had previously had and with that came strong beliefs that they were able to abstain from alcohol and drugs and remain clean and sober throughout their lives (Wood, 2002). Many of the individuals that were examined in this particular study had very low levels of self belief and extremely low levels of holistic health (Wood, 2002). Many of them began using drugs or alcohol at a young age, had trouble with the law, had been abused, and had also been dealing with academic problems (Wood, 2002).

Treatment not only looked at getting them off of drugs and alcohol but also addressed the various issues that they had in their lives that may have led them to drug and alcohol abuse (Wood, 2002). At the particular treatment center that was studied 10% of those that were admitted to treatment left early and without completing services because of various issues such as fighting, continuing to use drugs or alcohol, having legal charges brought against them, or simply being unwilling to participate in any more treatment (Wood, 2002). Recidivism was not something that the treatment center had strong data to document but it was estimated that approximately 5% of those that were treated at the center would relapse and return at some point (Wood, 2002).

The 10% rate of individuals that left prior to completion, however, indicates that roughly 90% of the individuals that began treatment got through it successfully and completed it (Wood, 2002). Completing a discharge successfully included meeting all of the treatment goals, developing a stronger insight into strengths and weaknesses, participating in AA or another type of approved drug or alcohol treatment program, making appropriate living arrangements for home, an increase in self-esteem, a plan of continuing care, and completing treatment goals that were largely educational (Wood, 2002).

When one of these individuals is discharged there are outpatient treatment services made available to that client and the client is usually required to utilize these services after discharge (Wood, 2002). A first appointment is usually within three days of the date of discharge from the center (Wood, 2002). A physician or psychiatrist may also be needed for further treatment and referrals are made for these individuals if it is necessary (Wood, 2002). Many of the individuals that successfully complete these drug or alcohol treatment programs also have difficulties with the legal system and planning the discharge of one of these individuals with the parole officer is also often necessary (Wood, 2002). Those that are parents are often in danger of losing their children, or have already lost them and are trying to go through the necessary steps to regain custody of them.

Family counseling is quite often recommended as well as most individuals can benefit from this (Wood, 2002). Discharges that occur during school years necessitate arrangements with the school so that an individual is allowed to return (Wood, 2002). It is important to understand how schools can help these adolescents return and keep their relapse rates low (Wood, 2002). They should be supported with a collaborative and open relationship between the schools and the treatment facilities and readmission policies and referrals should be commonplace for any student that indicates difficulties (Wood, 2002). Those who educate individuals about health at schools and those who work in school nurses offices or on the counseling staffs can very significantly influence the treatment and the recovery of adolescents who have trouble with substance abuse (Wood, 2002).

It has been almost 15 years since the various stages of substance abuse that led to dependency and abuse were defined. Since that time there have been policy statements published and many roles that have been defined (Indications, 2000). Sometimes specialized treatment has also been needed for various adolescent patients and adult patients as well (Indications, 2000).

It is very difficult to evaluate individuals that are in the earliest stages of substance abuse (Indications, 2000). It is common for individuals to experiment with various chemical chemicals including nicotine at a young age, but condoning or trivializing these experiments often just make them worse (Indications, 2000). Marijuana, alcohol, and inhalants are often called gateway drugs and even a first use of these is often trivialized by adults (Indications, 2000). When this is done tragic consequences such as unintentional injuries or even death can eventually result (Indications, 2000). Those who begin to use drugs are often very naive about what type of effects they will have and because they are uninitiated in its particular use and have no tolerance for its effects it can be especially dangerous (Indications, 2000). The substance use stages are important to note because they can have a strong effect on what comes later if they are not dealt with appropriately (Indications, 2000). For clarity of understanding the substance use of criteria table is reproduced here (Indications, 2000).

TABLE 1. Stages of Substance Abuse

Stage

Description

Potential for abuse

Decreased impulse control

Need for immediate gratification

Availability of tobacco, drugs, alcohol, inhalants

Need for acceptance

Experimentation: learning the euphoria

Use of inhalants, tobacco, marijuana, and alcohol with friends or family

Few, if any, consequences

May increase to regular use

Little change in behavior

Regular use: seeking the euphoria

Use of other drugs, eg, stimulants, lysergic acid diethylamide (LSD), sedatives

Behavioral changes and some consequences

Increased frequency of use; use alone

Buying or stealing drugs

Regular use: preoccupation with the "high"

Daily use of drugs

Loss of control

Multiple consequences and risk-taking

Estrangement from family and "straight" friends

Burnout: use of drugs to feel normal

Use of multiple substances; cross-addiction

Guilt, withdrawal, shame, remorse, depression

Physical and mental deterioration

Increased risk-taking, self-destructive behavior, or suicidal behavior

Source: Indications, 2000.

As adolescents begin to experiment with drugs pediatricians have very important roles in educating the adolescent and his or her family (Indications, 2000). Counseling and follow-up appointments in the doctor's office may be all that are actually needed if there have not yet been any type of adverse consequences (Indications, 2000). For adolescents who have experienced adverse consequences such as intoxication injuries, truancy, trouble with the law, declines in school performance, and physical or mental deterioration, intervention and treatment programs are clearly indicated (Indications, 2000).

Confidentiality is extremely important in establishing any type of relationship with an adolescent but sometimes doctors must go beyond this and discuss the problems with parents if the behavior that an adolescent is engaged in is becoming dangerous enough to justify it (Indications, 2000). If the parents are also substance abusers, the problem is obviously compounded. Depending on what type of circumstances surround it, maintaining confidentiality with the family and the substance abuser may not always be possible (Indications, 2000). Any type of substance abuse that is associated with legal problems, school or job failures, injuries, danger to self or others, or physical or mental deterioration requires that individuals be made aware of the problems that the person is facing so that family and others can become involved in the process of intervention (Indications, 2000).

Office visits that follow-up from one that indicates drug or alcohol abuse allow doctors to assess use or abuse of drugs or alcohol and whether or not it is continuing (Indications, 2000). Families should then be advised by doctors to set firm and very strong rules about involvement with alcohol, tobacco, and other drugs and the consequences that will take place for use of any of these should be clearly defined so that everyone understands what type of expectations must be met (Indications, 2000). Behaviors by teachers, parents, health-care professionals, and other adults that allow alcohol, tobacco, or other drug use to take place must be recognized and strictly avoided (Indications, 2000).

These include tolerating erratic behavior by an individual, allowing the individual to associate with those that are known to abuse drugs or alcohol, and permitting declines in job or home life performance without explanation (Indications, 2000). Doctors must become part of the chain of various individuals that work to emphasize the message of nonuse of drugs and alcohol by providing information that is both consistent and clear to parents and also maintaining a relationship that is caring and trusting (Indications, 2000). Emphasizing the health risks of drugs and alcohol while maintaining an approach that is not judgmental is extremely important to help these individuals and allow them to realize that treatment may be their best option (Indications, 2000).

Some people are quite capable of discontinuing any type of use of drugs or alcohol simply by making a personal commitment to do so and these individuals generally have family support or self-help groups as opposed to any type of formal treatment (Indications, 2000). As they continue to develop most individuals that have trouble with drugs or alcohol when they are young will stop abusing these types of things by the time they reach early adulthood (Indications, 2000). The goal for doctors should not only be to recommend treatment but also to help identify some of the consequences that utilizing alcohol or other drugs can place on one's lifestyles, and what these consequences can be to others, such as children.

It is hoped that this will motivate the individual to get the type of help that he or she needs in order to create and maintain a recovery (Indications, 2000). This can be very difficult with a parent and it has only been recently that any type of literature is actually emerging on motivational interviewing and other techniques to help encourage these individuals to change the way that they do things and remove themselves from problems with drugs and alcohol (Indications, 2000). Doctors can help enhance this by encouraging evaluations of these individuals and expressing the concerns that they have (Indications, 2000). In order to have a successful recovery, individuals must stop denying that abusing drugs or alcohol is what is causing the problems that he or she is experiencing (Indications, 2000).

Deciding when and where the individual should be referred for treatment is often much more complicated (Indications, 2000). Many treatment programs require that an individual be diagnosed with abuse or dependence based on the Diagnostic and Statistical Manual of Mental Disorders (Indications, 2000). The criteria for substance abuse and the criteria for substance dependence from this manual are reproduced here (Indications, 2000).

TABLE 2. DSM-IV Criteria for Substance Abuse

1. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 (or more) of the following, occurring within a 12-month period:

a. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (eg, repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) b. recurrent substance use in situations in which it is physically hazardous (eg, driving an automobile or operating a machine when impaired by substance use) c. recurrent substance-related legal problems (eg, arrests for substance-related disorderly conduct) d. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (eg, arguments with spouse about consequences of intoxication, physical rights)

2. The symptoms have never met the criteria for substance dependence for this class of substance.

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (pp182-183).

Source: Indications, 2000.

TABLE 3. DSM-IV Criteria for Substance Dependence maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period:

1. 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

2. withdrawal, as manifested by either of the following:

a. The characteristic withdrawal syndrome for the substance b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

3. The substance is often taken in larger amounts or over a longer period than was intended

4. there is a persistent desire or unsuccessful efforts to cut down or control substance use

5. A great deal of time is spent in activities necessary to obtain the substance (eg, visiting multiple doctors or driving long distances), use the substance (eg, chain-smoking), or recover from its effects

6. important social, occupational, or recreational activities are given up or reduced because of substance use

7. 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 (eg, current cocaine use despite recognition of cocaine-induced depression or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (P181)

Source: Indications, 2000.

There are some treatment programs in communities that have prevention service and education that are very much available for individuals that are identified early on in the process of becoming dependent (Indications, 2000). Many practitioners that deal with primary care do not have the working knowledge of these diagnostic manuals that they really need and therefore they need to gain a more thorough understanding of substance dependence and substance abuse criteria that can help them determine who actually needs to be referred and where that person should be sent (Indications, 2000).

Denial and resistance are quite common with substance abuse in many people and are quite expected. It is very important that the best recommendations for the person and his or her family are made by the doctor while that doctor attempts to also remain supportive and available (Indications, 2000). Sometimes a duel diagnosis is made based on substance abuse and a psychiatric diagnosis and there are many additional concerns that come with this (Indications, 2000).

Conduct disorders and major depressive disorders have often been seen to coexist in individuals that choose to use alcohol, tobacco, and other drugs (Indications, 2000). A high prevalence of this comorbidity has been seen in substance abuse in patients that are receiving inpatient treatment but how many patients actually exhibit psychiatric systems because of the substance abuse and how many have an actual psychiatric diagnosis that is separate from the substance abuse is still unclear (Indications, 2000). Many individuals believe that considerations based on the methodology of particular studies including how long an individual abstains from drugs or alcohol before diagnosis is made, what type of population is sampled, and what the perspective of the examiner actually is help to affect the rates of prevalence for psychiatric disorders in patients that are substance abusers and also account for some of the variability that may take place (Indications, 2000).

It is believed that the rates of prevalence for these types of psychiatric disorders and substance abuse in individuals are elevated artificially by a tendency to establish some type of diagnosis before some of the symptoms of psychiatric problems that may be secondary to the substance abuse actually abate (Indications, 2000). Ideally, for a diagnosis of any type of psychiatric disorder comorbidity to be made, the individuals must be observed for at least one month after drug use has been discontinued (Indications, 2000). The current era tends toward either very brief hospitalizations for drug issues or no hospitalization at all and therefore it may make more sense to make a diagnosis and prescribe medication especially if the psychiatric disorder symptoms appear to predate the beginning of substance abuse or if there is any type of psychiatric disorder in the family history (Indications, 2000).

Being made aware of the manifestations and the prevalence of any type of psychiatric diagnoses in those who are substance abusers is essential to have quality treatment and clinicians need to be aware of the comorbid conditions that are often seen (Indications, 2000). There have not been any type of large-scale population studies conducted on these individuals but some studies have looked toward estimating alcohol abuse and drug abuse disorders as well as mental disorders in samples of adults (Indications, 2000). Of those individuals that were seen to have problems with alcohol 37% of them had some other type of mental disorder and the highest prevalence of mental disorders were antisocial personality disorders, affective disorders, and anxiety disorders (Indications, 2000).

Over 50% of those individuals studied that had drug problems that were not alcohol related had comorbidity with another type of mental disorder (Indications, 2000). Twenty-six percent of these individuals had affective disorders, 28% showed evidence of anxiety disorders, and 18% of them had antisocial personality disorder (Indications, 2000). Only 7% had something considered extremely serious such as schizophrenia (Indications, 2000). The study did indicate that the impression that comorbidity rates for these types of disorders were much higher for patients that were receiving treatment in institutions than they were in the general population appeared to be accurate (Indications, 2000).

For doctors to best serve their patients in the substance abuse area, they need to be aware that disruptive behavior disorders, affective disorders, and anxiety disorders are the diagnoses that are going to be much more likely encountered in their offices than others (Indications, 2000). There are four important ways that these doctors can help their patients the most and these are important enough to be included here (Indications, 2000).

1. Conduct a complete evaluation of each patient that includes a comprehensive psychosocial history and physical examination, as well as a mental status examination and an inquiry into other psychiatric symptomatology by using information obtained from collateral sources, such as family or friends;

2. Have a high index of suspicion for psychiatric comorbidity in individuals whose conditions do not respond to treatment or who are presenting problems in treatment;

3. Individualize treatment to accommodate other psychiatric diagnoses; and 4. Have a working relationship with and know when to consult a mental health specialist. The close integration of mental health care and primary care are important; managed care arrangements that separate mental health and addiction services from primary care make this coordination more difficult.

Source: Indications, 2000.

Where these substance abusers should be referred is becoming increasingly important because getting the correct level of care is vital for these individuals (Indications, 2000). When these individuals are seen to have abuse or dependence on a particular substance receiving this care from the right place and the right type of treatment is vital to their continued success (Indications, 2000).

Comprehensive assessments are often done to match these people with the best treatment program possible and they look at the history of drug or other substance abuse, the type of previous treatment these individuals have had, whether there are any comorbid psychiatric conditions, what types of social and family issues the individual may be facing, what type of affect the treatment will have on their education and job, the support system that the person has, and how much motivation an individual has for treatment, among other things (Indications, 2000).

There are specific criteria that should be looked at when deciding what type of treatment program an individual should be sent to and there are also many recommendations that can be made for doctors (Indications, 2000). These are both very significant and because of this they have both been reproduced here in their entirety (Indications, 2000).

Criteria for the Selection of a Substance Abuse Treatment Program

Appropriate substance abuse treatment facilities for all individuals, but especially for the growing number of children and adolescents, must have staff with adequate experience in dealing with specific age groups, family groups, and the issues that they are facing. The following criteria may be useful in evaluating an inpatient or outpatient substance abuse treatment program.

1. The program views drug and alcohol abuse as a primary disease rather than a symptom.

2. The program includes a comprehensive evaluation of the patient and appropriately manages or refers for treatment any associated medical, emotional, or behavioral problems identified in the initial assessment.

3. The program adheres to an abstinence philosophy. Any use is abuse. Drug use is a chronic disease, and a drug-free environment is essential. Tobacco use ideally should be prohibited, or nicotine cessation treatment should at least be part of the overall treatment plan.

4. There is a low ratio of patients to staff. Treatment professionals should be knowledgeable in the treatment of chemical dependency and behavior and development.

5. Professionally led support groups and self-help groups are integral parts of the program.

6. Adolescent groups are separate from the adult groups if both are treated at the same facility.

7. The entire family is involved in treatment. The program relates to parents, children and all patients with compassion and concern with the goal of reunification of the family whenever possible.

8. Follow-up and continuing care are integral parts of the program.

9. As progress is made in the program, patients have an opportunity to continue academic and vocational education, or their jobs, and are assisted in restructuring family, school, and social life.

10. The program administration discusses costs and financial arrangements for inpatient and outpatient care and facilitates communication with managed care organizations.

11. The program is as close to home as possible to facilitate family involvement, even though separation of the parent from the rest of the family may be indicated initially.

Source: Indications, 2000.

Where adolescent drug and alcohol abusers are seen, there are also some specific recommendations for pediatricians:

1. Pediatricians need to become familiar with the patterns of adolescent nicotine, alcohol, and drug use and the stages of substance abuse. Knowledge of the DSM-IV and DSM-PC criteria for diagnosis is useful for differentiating experimental use from problem use.

2. A thorough psychosocial and medical assessment of the patient is essential before making a referral for evaluation or treatment. Familiarity with the levels of treatment available and the multidimensional assessment criteria used to determine the intensity of services required can assist the pediatrician to make an appropriate referral.

3. Substance abuse is a potentially fatal disease. Use to the point at which school, activities, home, or work is affected represents symptomatic substance abuse and usually warrants parental involvement and a comprehensive interview and assessment.

4. Awareness of the high prevalence of psychiatric disorders among adolescents who abuse or are dependent on psychoactive substances will affect the decision as to where to refer the adolescent. If the pediatrician suspects a comorbid psychiatric diagnosis and needs assistance in determining appropriate treatment, psychiatric consultation should be obtained.

5. As advocates for adolescents and families requiring substance abuse treatment, pediatricians have the opportunity and obligation to become familiar with professionals and programs in their communities that provide education, prevention, and treatment services, including smoking cessation. A close working relationship facilitates referrals and communication.

6. Pediatricians also can advocate with local managed care organizations to provide quality mental health and substance abuse services that are appropriate for specific ages and developmental stages and that are integrated with primary care. Knowledge of the criteria for selecting an adolescent treatment program and the American Society of Addiction Medicine Patient Placement Criteria form the basis for these advocacy efforts.

7. Pediatricians must be familiar with state and federal regulations governing confidential exchange of information about substance abuse treatment. These are available from the state alcohol and substance abuse treatment regulatory agencies.

Source: Indications, 2000.

Looking at how those who have used alcohol and drugs during adolescence have changed their lives as also significant, because many of these individuals will grow up to have families of their own. Not abusing drugs or alcohol is not only important to their health and safety, but to the future health and safety of their children as well. Some are not able to do this and even though they fight their addictions quite strongly they succumb to them as they get older. However, some are able to survive and go on to better lives that are free from addiction. The 12-steps that Alcoholics Anonymous presents have some significance because they indicate that there is a definite plan for those that wish to be free of alcohol and other drug dependence. In order to have a better understanding of what these are and how they are taught the 12-steps are reproduced here.

The Twelve Steps of Alcoholics Anonymous

1. We admitted we were powerless over alcohol - that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics who still suffer, and to practice these principles in all our affairs.

Source: Long, 1999.

Being able to surrender is often the most difficult thing for those who have trouble with substance abuse and know that they need help and this is particularly true of parents, as they fear for what might happen to their children (Long, 1999). Many of these who are strongly overwhelmed by the addictions that they have are driven by degradation, fear, and desperation to seek a higher power (Long, 1999). Many of the surrender stories that adult alcoholics have are chronicled in various studies but little research has been done into adolescents and how they respond (Long, 1999). For some of the adults the realization comes that they are becoming just like the parents that they hated when they were young or that they are killing themselves with their drinking (Long, 1999). Sometimes this starts the process of surrender.

Most adolescents, however, are not raising children and are not being confronted with any type of severe health problem due to utilizing drug and alcohol abuse for many years (Long, 1999). Because of this the experiences of surrender that some of them have maybe quite unique (Long, 1999). Getting through the fourth through twelfth steps of the Alcoholics Anonymous information listed above may also be very difficult for many adolescents (Long, 1999). Many of these involve repair or integration of what has sometimes been termed the 'divided self' by helping to atone for the past mistakes that they have made, praying for the strength to avoid repeating these mistakes in the future, identifying defects in their character, and working with others that are addicts or alcoholics (Long, 1999).

Drug use can work to arrest much of the emotional development that individuals go through and therefore these individuals may have very little activity that they can reform, rediscover, or repair (Long, 1999). If adolescents can be kept sober until they have emotionally progressed through childhood and come to a struggle with their identity then they have a very strong chance of being able to stay sober and clean in the future, which will greatly benefit the families that they will create and the future generation (Long, 1999). There have been mentions made of various problems that recovering adolescents face. Being able to tolerate emotions is something that adolescents learn and when they involve themselves with chemical dependency and addiction early in their adolescent years development of this emotional tolerance is strongly inhibited (Long, 1999).

Among those adolescents that are in the middle of the adolescent age group a critical shift takes place and they begin to avoid conflicts and develop a sense of intimacy, although false, with peers that are also abusing drugs or alcohol (Long, 1999). Older adolescents that have addiction and chemical dependency issues often have a great deal of difficulty with being individuals and they become very dependent on their peers and their family (Long, 1999). It is believed, however, that adolescence is a very good time for healing if that healing is addressed appropriately (Long, 1999). If the healing is not addressed, the abuse continues, and the adolescent grows up to have a family of his or her own, relating to his or her children and becoming clean and sober may be especially difficult based on the dependence that they have toward others.

Parenting programs for those that are struggling with drug and alcohol abuse is extremely critical because parental nurturing or the lack of it seemed to be a large factor in the lives of many adolescent drug and alcohol abusers and drugs or alcohol were utilized as a way to fill that up (Long, 1999). One study that was done with a small sample of individuals that have dealt with drug or alcohol problems when they were adolescents looked at the variation with regards to socioeconomic status and gender but it suggested that surrendering to the problem and recovering from it is very similar for most adolescents (Long, 1999).

The study looked at individuals that came from affluent homes, middle-class homes, and poverty, as well as some that had been physically and sexually abused (Long, 1999). All of the individuals in the study had trouble with sexual boundaries and all were also suicidal at least at one point in their adolescents (Long, 1999). However, many studies have predicted very high long-term relapse rates for adolescents who abused drugs or alcohol but the study looked at here indicated that this was not the case (Long, 1999). All of the participants in that particular study experienced surrender and they also had long-term recovery periods (Long, 1999).

Contrary to many of the other expectations that were seen regarding the differences between adults and adolescents, the guilt over the past actions that these individuals had taken as well as the fear of dying from what they were doing were strong motivators for the adolescents just as they were for adults who also chose to stop drinking or using drugs (Long, 1999). The participants in that particular study did not respond well at all to lecturing or accusations but responded much better to care that was demonstrated by individuals who were obviously concerned for their well-being (Long, 1999).

This has also been noted in other research and these individuals found the help that they needed from caring individuals when they felt they were ready to change (Long, 1999). Regardless of the reasons that the parents or other individuals helped these adolescents they did receive help and that was the most important and significant factor in their recovery (Long, 1999). There were many identity issues that these individuals had to deal with because of their emotionally arrested development due to drug and alcohol abuse (Long, 1999). All needed help with relating to members of the opposite gender and all had issues with intimacy (Long, 1999). They also faced the same type of problems that any individual who is a substance abuser must deal with such as alienation, shame, and grief (Long, 1999).

These were the same in adolescents as they were for adults. Many of these individuals were able to trust adults, group members, or other adolescents and because these individuals have confronted the same types of feelings the adolescents in this particular study believed that they actually belonged somewhere (Long, 1999). Family members that were recovering, friends that vowed to help them, and their sponsors as well all listened to their stories and helped to set good examples to keep them clean and sober in the years ahead (Long, 1999). These individuals were able to find connections that they very desperately needed and this also help them to better themselves further (Long, 1999).

Many researchers deemphasize the belief in God that most of these groups hold in high regard and even though it is not the place of research to discuss theology the belief in God that these groups have appears to be a very key element in the ability of these individuals to surrender (Long, 1999). This helps ease their guilt and makes them feel as though they are forgiven (Long, 1999). At the same time they are able to shed much of the shame that they have felt for what they have done. These individuals can surrender to the higher power that they believe in and therefore they can feel forgiven and be able to forgive themselves as well (Long, 1999). When they do this they leave the past behind them and the identities that they develop in the future are much more positive.

Looking at different family factors and other issues are also important when studying substance abuse and addiction in individuals (Winters, 1999). It appears that there may be a relationship between addiction to drugs and alcohol in adolescents as well as mood disorders in various family factors such as the problem-solving styles a family has, how satisfied an adolescent is with his or her family, and how much marital discord is seen between parents (Winters, 1999). In general, the nuclear family has been seen as a central institution of society and has also been seen to have the strongest responsibility for socialization of children (Winters, 1999). This is one of the main reasons that parents should stay away from drugs and alcohol and teach their children by example.

An adolescent's ability to learn behavior that is acceptable both psychologically and socially depends very strongly on what type of interactive processes the family has, how well the family reacts with society, and what type of internal dynamics the adolescent may have in his or her personality (Winters, 1999). Quite frequently, the inability of the adolescent to internalize appropriate standards for behavior can partially be traced to interaction patterns in his or her family that seem to be dysfunctional (Winters, 1999). Quite frequently these family factors are implicated when it comes to substance abuse and addiction in adolescents (Winters, 1999). There are many different dimensions of this abuse and factors such as economics, age, ethnic or social group, developmental issues, family dynamics, and peer pressure all work in some ways to contribute to the development of substance abuse problems and addiction in adolescents (Winters, 1999).

Important areas to focus on in the family issue are the interpersonal dynamics that may indicate or work to explain abusive behavior when it comes to drugs and alcohol (Winters, 1999). In some families there have been dynamics observed whereby the adolescent is engaging in various forms of substance abuse because they have parental noninvolvement, emotional distancing, extremely low expectations from their parents, passivity on the part of their parents, substance abuse that has been going on for many generations, and very deviant behavior (Winters, 1999).

Families that have adolescents that are involved with addiction and substance abuse report scapegoating, less conversation, more trouble with boundaries and values, and have also been seen as being dysfunctional in many other areas (Winters, 1999). Families that are healthy generally incorporate several other characteristics that are not seen in families that have adolescents that abuse substances (Winters, 1999). These include direct and clear expressions of communication, a strong commitment to each other, problem solving skills that are creative and effectively used, and an ability to maintain various relationships within the community (Winters, 1999).

Studies that have looked at the family of the adolescent that has addiction issues suggest that the specific families do not have enough cohesion and are split by many different types of alliances (Winters, 1999). In other words, the parents do not relate in any type of unified manner to the child (Winters, 1999). When looking at problem solving skills in this adolescent population of dysfunctional families one study indicated that having a crisis to deal with, that of the addicted individual, is one of the only ways that these type of families can pull together and attempt to solve problems as a family (Winters, 1999).

The substance abuse programs that are creative for individuals today on an inpatient basis either use addiction and substance abuse models that have been designed for adults, address the issue as more of a clinical problem, or combine these two various approaches (Winters, 1999). This would indicate that there is not enough knowledge regarding different familiar factors that can contribute to or cause substance abuse (Winters, 1999). A consequence of this is that the treatment measures and prevention measures that could be utilized to save adolescents and these families often lack direction and focus (Winters, 1999). These things can be gained through looking at the specific features that these dysfunctional families have and creating a descriptive analysis that deals with them (Winters, 1999). This is important, as it has already been mentioned how parental substance abuse can create a whole new generation of substance abusers.

Having a lot of conflict between parents, not having enough support within the family, and confusing or distorting the type of communication that takes place between family members are often seen to be much more prevalent in families that have adolescents that have addiction and substance abuse problems and have been treated for varieties of disorders in clinical settings (Winters, 1999). Adolescents will not work to make serious changes in their lives unless the families that they come from are able to deal with these changes and look at the adolescents in a new way (Winters, 1999). Because these adolescents are part of strong family system he or she may be expressing the various relationships that occur within his or her family unit or could also see himself or herself as somewhat of a scapegoat for frustration and other family issues (Winters, 1999).

These dynamics and family issues have to be addressed in adolescent addiction if any type of changes is going to occur (Winters, 1999). This is true whether the individual goes to treatment willingly or whether the treatment is court ordered (Winters, 1999). An additional issue is that these substance abusing individuals have families that are not good at problem solving and many of these families have histories of emotional or substance abuse issues (Winters, 1999). Because the problem solving skills in these families are somewhat less effective the individual has more trouble remaining clean and sober once treatment has been completed (Winters, 1999).

In families that are healthy, any types of problems that an individual faces are resolved or solved in any way that is realistically possible and often this encourages family function very strongly (Winters, 1999). There is not enough research done in the families of adolescents that are addicted to drugs and alcohol to have a strong impression of the problem solving patterns and skills that these individuals have (Winters, 1999). There have been studies that have indicated that including parents in the treatment of an adolescent who is battling drug or alcohol addiction helps to maintain emotional and behavioral gains that were created during treatment after the adolescent has been discharged (Winters, 1999). It would seem, based on this, that including children in the recovery of parents that are substance abusers would have this same affect on the parents.

Other reviews of some of the literature on the subject shows that these individuals that are engaging in substance abuse behavior often have clinical assessments that are placed upon parent education and emotional support rather than treatment interventions that are specific to the individual (Winters, 1999). In other words, they rely too heavily on a parent being aware of the situation and being educated about it and the parent also being there to support the adolescent emotionally (Winters, 1999). These are important issues but they are not the only things that need to be dealt with and specific treatments to keep the adolescent clean and sober should involve more than parental support and caring (Winters, 1999).

Not having enough clinical information and not having enough empirical research has restricted the development that could have taken place in treatment goals despite the fact that family involvement is very important in the treatment plan but is not the only thing that should be considered (Winters, 1999). Looking at similarities and differences in families that are considered normal as opposed to families that have individuals with addiction or substance abuse problems is important so that family roles, family satisfaction, problem solving communication skills, and marital adjustment can all be studied (Winters, 1999).

Determining whether an individual goes to treatment willingly is very important and some of what may determine whether an individual will be willing to go to treatment is how that individual feels about his or her family (Winters, 1999). Observing the problem solving abilities regarding communication, flexibility, and resolving issues are very important because it is assumed that there are a great deal of differences between those families that are considered normal and the families are considered dysfunctional (Winters, 1999).

In one such study done about family dynamics when it comes to adolescents and addictive behaviors, adolescents were asked to complete a questionnaire which looked for either the presence or absence of any type of chemical dependency and the extent of feelings and honesty that these individuals might have toward this issue (Winters, 1999). In individuals that came from the considered normal group all listed themselves as nonabusers and all were evaluated as giving an honest response (Winters, 1999).

Five of the troubled group honestly admitted to alcohol use that was considered significant and four of those individuals also had drug use (Winters, 1999). Many of the families also rated their marriages and family relationships as being unhappy or maladjusted and this was seen more strongly for the fathers in the group than for the mothers (Winters, 1999). Family satisfaction was also relatively low with many of these individuals (Winters, 1999). The study was not able to show that there were specific characteristics that represented distinctions between families that have adolescent children that did not have addiction problems and families that did have these addiction issues (Winters, 1999).

However, there were trends that were seen regarding the degree of family health that was perceived, the communication and problem solving that families had, and the marital happiness or adjustment seen between spouses (Winters, 1999). Literature that currently deals with this issue suggests that happy marriages may indicate more positive behavior in adolescent children (Winters, 1999). Not all studies support this issue, however. The study that was done showed also married couples that were studied, with very few exceptions, to be relatively happy with their marriages and accommodating to one another (Winters, 1999). The study, however, required that families not be divorced or separated in order to be able to participate and so therefore this could have raised the expected level of marital satisfaction to some degree (Winters, 1999).

There were some stepparent families but most couples reported having long marriages and the hypothesis could therefore extend to the fact that these individuals have learned to accommodate their spouses after this period of time and this is why the marital satisfaction was relatively high (Winters, 1999). Identifying dysfunctional families and their specific features early on has clinical implications that are very important to individuals that may abuse substances (Winters, 1999). It could help prevent more severe dysfunction of families by the time therapists for these families find that there is a need for development of communication techniques and more appropriate other issues (Winters, 1999).

It could also help to shorten family treatment when these individuals do go for counseling if the dysfunction is caught early before it has a strong chance to develop (Winters, 1999). Assessment procedures such as the one performed in this particular study could have many different uses with only one of these uses being about the individuals that are struggling with drugs and alcohol and how they may be helped (Winters, 1999).

Whether or not an adolescent has been exposed to alcohol before being born also may affect the substance abuse problems that the child has later in life (Falek, 2003). This is one of the other important reasons that parents should avoid drugs and alcohol, and that they should seek treatment if they feel that they cannot do this. Many people do not understand the dangers of drugs and alcohol during pregnancy. Two studies that they have been conducted on those that have been exposed to alcohol while still in the womb have indicated many developmental and behavioral difficulties (Falek, 2003). Many of these individuals are born with fetal alcohol syndrome and they have problems with intellectual functioning, issues with psychosocial areas, and physical characteristics that are abnormal (Falek, 2003). Some also suggest that being exposed to alcohol in this way is also associated with behavior that is criminal or delinquent during adolescence (Falek, 2003).

These conclusions have been largely based on adolescents that are already referred for treatment or have been involved in the criminal justice system (Falek, 2003). It is difficult, therefore, to determine whether the samples are actually representative of what is found in general when looking at adolescents with fetal alcohol syndrome (Falek, 2003). Looking at behavior in a sample that is not clinical is much more important and included among the sample are those that are severely affected, those that are not as strongly affected, and a control group (Falek, 2003).

In addition to looking at whether these individuals have fetal alcohol syndrome also looked that are the other risk factors relating to delinquent behavior such as peer pressure and marital discord (Falek, 2003). This type of approach should be more helpful in understanding what type of behavioral problems are reported and what type of environmental influences must be taken into consideration when looking at how these individuals develop (Falek, 2003). Looking at the development of these individuals is important and they must be contrasted by looking at a group of individuals that have similar socioeconomic and ethnic backgrounds but were not exposed to alcohol while their mother was pregnant with them (Falek, 2003).

There have been many different effects documented, including those dealing with intellectual functioning and growth, where fetal alcohol syndrome is studied and adolescents that were exposed alcohol in the past are quite often reported to have psychosocial and behavioral deficit areas (Falek, 2003). These are considered to be secondary disabilities and are not generally present when the child is born (Falek, 2003). They develop as a response to many different environmental factors over time and seem to cause social and emotional behaviors that are maladaptive (Falek, 2003). If this is the case, specific intervention may be possible in order to help decrease not only the occurrence but the severity of these specific disabilities (Falek, 2003).

In various studies that have been done regarding secondary disabilities it has generally been reported that those that were referred to clinical treatment for fetal alcohol syndrome tend to have problematic or delinquent behavior as well (Falek, 2003). Over 60% in one particular study had difficulties with police, 60% had school experiences that were disruptive and upsetting, 50% had sexual behavior that was deemed inappropriate and 30% had problems with alcohol or drugs (Falek, 2003). Other studies done in the past on this issue reported similar problems and percentages (Falek, 2003). There appears to be a strong association between alcohol exposure prenatally and delinquent status as an adolescent (Falek, 2003).

A study that looked at adolescents that had committed or pled guilty to various criminal offenses and been remanded for psychiatric treatment on an inpatient basis found that over 23% of these adolescents had diagnoses related to fetal alcohol syndrome (Falek, 2003). Other studies have shown results that have been much more mixed. Having alcohol exposure prenatally was associated with scores that were higher on externalizing or delinquency as rated by parents or caregivers in some studies (Falek, 2003). However, other studies showed that scores were not elevated on aggression or delinquency in these alcohol affected individuals (Falek, 2003).

How severe these effects are and how strongly they affect social and behavioral issues tend to vary (Falek, 2003). Some individuals were exposed much more strongly to alcohol in their prenatal environment and therefore they have many more problems with delinquency and characteristically have the dysmorphic appearance as well (Falek, 2003). Some researchers see little difference between groups that were affected strongly to alcohol and groups that were affected only slightly when looking at their personality and the types of behavior that they have but other researchers see a very strong correlation between how much alcohol an individual consumed while she was pregnant and the problems that her child will have in adolescence (Falek, 2003).

It is fascinating that any of these children that were affected so strongly by alcohol would turn to alcohol or drugs in adolescence and this begs the question as to whether alcoholism is something that can be created in an individual rather than a learned behavior as that individual grows older (Falek, 2003). There are findings dealing with these individuals that were affected by alcohol and what type of behavior they show later in life, but they are still relatively inconsistent. It is clear, however, that being exposed to alcohol prenatally does affect individuals to some extent.

Many of the studies have been done on those that have already been referred to treatment and naturally these individuals are much more likely to have behavioral problems, drug and alcohol problems, or other issues. Other samples that have been selected involve those that have already been involved with the law or criminal behavior (Falek, 2003). Information that comes from parental reports of personality or behavior based on various rating scales have also been very inconsistent (Falek, 2003). The characteristics that are seen in these clinical samples and not having strong control groups may be some of the problems when it comes to the outcomes of these types of studies (Falek, 2003).

It is also quite possible that there are other risk factors as opposed to simply prenatal alcohol exposure that affect the behavior of adolescents so strongly and have not been evaluated on any type of consistent basis (Falek, 2003). The social environment and what type of characteristics an adolescent has are both recognized as being risk factors for delinquent behavior that includes alcohol and drug addiction (Falek, 2003). In discussing various risk factors for delinquency these risk factors have been grouped by their source or their influence (Falek, 2003).

This suggests that the characteristics of the adolescents and then the characteristics of the family are very strong initial sources of influence for an individual and how he or she will react as he or she gets older (Falek, 2003). As the world of this adolescent expands beyond his or her family and into the community the risk factors expand as well (Falek, 2003). These include the neighborhood, the school, and the peer group (Falek, 2003). Models such as this can be used as frameworks for examining the different types of influences that occur in families that abuse substances (Falek, 2003).

Prior researchers indicated that individual factors of these children that relate to delinquent behavior include externalizing many of the aspects of the behavior, problems with temperament, low intelligence rates, emotional withdrawal, and substance abuse or addiction (Falek, 2003). Other studies have also indicated a relationship between these externalizing behaviors and substance abuse (Falek, 2003). Risk of delinquency is also increased or decreased based on the type of family environment that is present (Falek, 2003). Adolescents that were exposed to alcohol in the womb may be strongly at risk for problems if the mothers continue to drink while still trying to function as a parent (Falek, 2003).

Parenting practices that include poor communication between the parent and the child, inconsistent discipline, and parental supervision that is at very low levels have also been related to delinquent behavior and drug or alcohol addiction (Falek, 2003). Parents that are involved in criminal behavior, are involved in substance abuse, or have mental health problems are also associated with delinquent or antisocial behavior in various adolescents (Falek, 2003).

Looking at the broader social environment is also important in determining what causes an individual to engage in behaviors such as alcohol and drug addiction (Falek, 2003). Associating with peers who are drug abusers, being exposed to a lot of violence in the community, living in poverty, having a high crime rate, and having no motivation in school or work as well as poor home-life performance are all related to this type of behavior in individuals (Falek, 2003).

Particularly at risk for these types of problems are adolescents that have parents that abuse substances (Falek, 2003). Much of this is because adolescents see this behavior as acceptable if their parents are doing it and also because the alcohol or drugs that the adolescents may be interested in using are relatively easy to get because they are accessible in the home (Falek, 2003). A number of community, individual, and family factors help adolescents develop and determine whether or not they will develop delinquent behavior (Falek, 2003). Many of the factors of various families have consistently been shown to be related to these types of behaviors and this is especially true for substance abuse in parents that will likely raise substance abuse in children (Falek, 2003).

Of the individuals that have fetal alcohol syndrome and are referred for treatment greater stability in the family environment and having caregivers that generally are concerned about the well-being of the child help to protect against many of the secondary problems such as drug or alcohol abuse that these individuals can develop (Falek, 2003). Including these current risk factors in addition to the maternal alcohol use is extremely important when looking at delinquent behavior because it paints a stronger picture and a better understanding of some of the issues that these children are dealing with (Falek, 2003).

It is therefore hypothesized that delinquent behavior will often be higher in adolescents that were exposed to alcohol prenatally and that there are various predictor variables that can be related to these instances of delinquent behavior (Falek, 2003). Results of studies that look at these kinds of issues suggest that being exposed prenatally to alcohol is a risk factor but there are much more important risk factors available when determining whether an individual will have behavioral problems with drugs or alcohol (Falek, 2003). This is even true for individuals who have the dysmorphic facial features and other strong effects of fetal alcohol syndrome (Falek, 2003).

When delinquency is looked at as a comparison of individuals that were exposed to alcohol in the womb and those that were not there were no significant effects that related to prenatal alcohol exposure when it came to delinquent behaviors (Falek, 2003). No findings supported that any type of delinquency, including that of utilizing or abusing drugs or alcohol, had any type of direct relation to being exposed to alcohol in the womb (Falek, 2003). This was a very strong contrast to some of the clinical findings that have been seen in the past in samples of the teens that have been brought in for psychiatric assessment (Falek, 2003). However, many of the previous studies used participants that had already been involved in treatment or in legal trouble at some point because of various behavioral problems instead of simply looking at a group of individuals that had never been involved in these things before (Falek, 2003).

When samples were drawn simply from the community they appeared to be much more accurate in the information that they provided. The previous studies that indicated strong correlations between fetal alcohol syndrome and other delinquency problems also did not have control groups that had similar social and economic backgrounds so that a comparison could be made (Falek, 2003). Composing these samples from individuals that were already in trouble with the law or had other problems and failing to add a control group may have shown differences between the analyses that were done previously and those conducted more recently (Falek, 2003).

The characteristics that families and children have, however, are very strongly related to delinquent behavior that they may show and this is stronger than the community and societal influences (Falek, 2003). Perceiving strong amounts of stress in life and abusing substances were two of the things that individuals saw as the highest predictors of having delinquent behavior (Falek, 2003). Family environment issues were also strong predictors of this type of behavior (Falek, 2003). Caregivers that offered very little warmth and supervision significantly predicted that delinquent behaviors would occur in these individuals (Falek, 2003). Also true of significant levels of delinquent behavior were verbal aggression in families and problems with conflict resolution (Falek, 2003).

The supervision a parent gives to a child and the relationship that the parent and child have with each other can be either risk factors or protective factors depending on the level of influence that these have (Falek, 2003). High levels of supervision help to protect against drug and alcohol abuse and low levels of supervision seem to increase the risk of these types of behaviors (Falek, 2003).

Why individuals go through treatment for alcohol and drug use is important to look at as to whether they manage to stay clean and sober (Marti, 2004). Research into this issue indicates that individuals will show improvements in the psychosocial functioning and reduction in the substance abuse that they had at one year follow-up appointments (Marti, 2004). However, in the year following treatment, relapse rates are very high and these range from 25 to 92% with a median of 44% (Marti, 2004). Beyond this initial event of relapse very little is known about the short-term patterns of individuals when it comes to drug and alcohol use following treatment (Marti, 2004).

Increasing the knowledge of the short-term patterns is very critical because there may be underlying mechanisms that need to be identified that will help with behavioral changes and early maintenance as well as help to avoid some of the risk factors that are seen most strongly as causing early reoccurrence of many of the substance abuse problems (Marti, 2004). Few articles and studies have looked at the short-term patterns of substance involvement when it comes to adolescents that have been treated (Marti, 2004). However, there have been long-term studies that have been done into this issue that have looked at the trajectories of alcohol involvement in adolescents involving treatment (Marti, 2004).

These studies of longer-term issues look at post treatment and various subgroups in an effort to determine whether individuals will return to the behavior that got them into treatment in the first place (Marti, 2004). In looking at clinical samples of individuals there are five specific trajectories that represent change in alcohol symptoms over one and three-year follow-ups (Marti, 2004). Three of these trajectories deal with improvement and represent 68% of the sample here while moderate improvement indicates 40% of the sample and problem issues indicate 9% (Marti, 2004). Studying individuals who were inpatients over the course of eight years identifies four trajectories (Marti, 2004). Twenty-two percent were abstainers, 24% considered themselves infrequent drinkers, 36% were drinkers whose increased use of alcohol grew with time, and 18% were considered to still be continuous and heavy users of alcohol (Marti, 2004).

In these types of studies the characteristics of these trajectories involve distinct predictors and specific outcomes (Marti, 2004). Lower levels of involvement with alcohol also were associated with lower levels of abuse and use of other types of drugs and those that abstained generally rated their psychosocial functioning as being better during follow-up compared with other individuals (Marti, 2004). These long-term follow-ups that deal with clinical samples of individuals that have been treated in the past have shown important information dealing with alcohol involvement and patterns of it into adulthood.

However, they have not characterized as adequately more of the finer patterns of alcohol use during the early part of recovery when the effects of treatment may be seen most strongly (Marti, 2004). Data that currently exists suggests that there are three specific patterns of alcohol use through the first one and one-half years of follow-up treatment (Marti, 2004). These include stable high, moderate, and low levels of use of alcohol (Marti, 2004). Too small sample sizes may not be able to define these trajectories as well as would be hoped, however, and they may work to obscure some of the important patterns of change that are seen in the short-term (Marti, 2004).

In the year following treatment very strong changes take place and further assessment is needed to help understand not only the nature of these changes but the rate at which they occur (Marti, 2004). Using steady patterns very intensively during this early recovery will help to determine not only the immediate impact that the treatment had on these individuals but the duration of the effects that took place during treatment (Marti, 2004). To help address these concerns studies have looked at assessments on a monthly basis of substance use and abuse in the one year following treatment for alcohol or drug abuse (Marti, 2004). There has been a relatively strong correlation reported in several studies that deals with abstinence on a post treatment basis and outcomes that are very positive for many individuals (Marti, 2004).

How many days an individual remains abstinent indicates important issues of change in alcohol use among these individuals (Marti, 2004). It is important to look at the percentage of days that an individual abstains within a specific time frame but also to look at the spacing between the various drinking days (Marti, 2004). Looking at these types of factors is extremely important for individuals because it may give information into drinking patterns (Marti, 2004). These individuals often have patterns of very heavy drinking and specific episodes and then go a large number of days where they do not drink at all (Marti, 2004).

Among adults that were recovering from treatment for alcohol or other substance abuse one, two, or four weeks of abstinence marked strong milestones during the early recovery (Marti, 2004). Spacing episodes of drinking out and being able to run together many consecutive days of abstinence can help to distinguish binging patterns in the short-term and may be particularly significant and important for these individuals (Marti, 2004). Looking at monthly reports of drinking patterns in the study researchers wanted to observe what type of trajectories were expected in short-term alcohol use (Marti, 2004).

Their hypothesized information included the fact that there would be consistently reported very low levels or abuse or those that abstained altogether (Marti, 2004). Also expected were groups that drank heavily regardless of treatment (Marti, 2004). It appeared that there would also be some that were initially abstinent and then had problems drinking, and then would abstain again (Marti, 2004). These individuals would show a pattern where the abstinence and the number of days that they were able to remain sober would slowly decline (Marti, 2004). The results of their study indicated that the hypotheses that they had created were largely valid and acceptable (Marti, 2004). The study looked at the use of alcohol trajectories over one year to determine whether there were specific trajectories that these individuals found themselves on (Marti, 2004).

Having intensive follow-up through interviews done on a monthly basis during early recovery provided a very unique opportunity to look at short-term patterns of use to see whether treatment effects remained effective (Marti, 2004). This was also fascinating because the risk for these individuals to return to the problems that they had in the past was very high during the first year (Marti, 2004). For both alcohol and other types of drug addiction as well, there were four short-term use patterns identified by researchers. These included high, decreasing, increasing, and low abstinence (Marti, 2004). Whether there were use patterns that were increasing or decreasing were not generally apparent from the means over monthly samples (Marti, 2004). These only came from looking at the entire study over the one year to see patterns that took place slowly (Marti, 2004).

Very similar to the results that were obtained during other studies on long-term effects, there were patterns of both high and low alcohol use in the short-term identified (Marti, 2004). Increasingly short-term patterns were also identified because of the more intensive assessment that took place (Marti, 2004). Having abstinence for a month at the one year follow-up may be reached by many different ways and the fact that there is increasing trajectory for more abstinence shows that the outcomes based on a single relapse need to be reconsidered (Marti, 2004).

These episodes of single abuse or single relapse must be considered within the broad pattern of change that takes place in the first year individuals are out of treatment because these various changes can still mark successful movement toward a specific goal (Marti, 2004). Interventions for substance abuse are very important but there are specific implications not only for the timing of these interventions but for the duration as well (Marti, 2004). By the ninth month of the study that was conducted the group that had decreasing abstinence had the same past month level of abstinence that was seen in the low abstinence group (Marti, 2004).

This indicates that those in the decreasing alcohol abstinence group may need additional interventions between the sixth and the ninth month as this period of change for this particular group appears to be very critical (Marti, 2004). There seems to be strong erosion of the gains that were made in treatment during that period of time and this is why this extra intervention may be necessary (Marti, 2004).

In contrast to this the group that had increasing abstinence over time showed a recovery process that was much more gradual and appeared to be either a learning curve, possible delayed effects from the treatment that took place, or effects of various other factors such as having increasing or stronger motivation to abstain from alcohol (Marti, 2004). For both alcohol and other types of substance abuse in this particular study the trajectory that dealt with high abstinence accounted for most of the samples (Marti, 2004). In other words, most individuals that went through treatment were able to mostly abstain from alcohol or other drugs for that first year (Marti, 2004).

These individuals had more motivation to abstain from substance abuse and took more action to change the kind of behavior that had caused them to get in trouble in the past (Marti, 2004). There were no separate trajectories identified for the relatively small number who abstained completely from any type of alcohol or other drugs during their follow-up year (Marti, 2004). However, when these complete abstainers were combined with those in the high abstinence group indicated by drinkers that do not have abuse or use problems outcomes and very modest levels of use of alcohol were comparable to those that abstain over one year (Marti, 2004).

These findings are for those that use alcohol and very little is known regarding the substance use outcomes or psychosocial outcomes of individuals who use low levels of other drugs on a short-term basis (Marti, 2004). Findings indicate that there has to be a readiness and motivation in order to change alcohol or other drug abuse and order to abstain from this type of use over the short-term and the long-term (Marti, 2004). There are many pathways that can be taken over the one year to still be identified as a high abstainer. The longer period of time that an individual abstains, however, the better off he or she will be when it comes to alcohol and other drug use (Marti, 2004).

Following these substance abusers and substance users on a longer period is also important. Since the previous information just looked at short-term outcomes, this particular information will look at more long-term outcomes. Both community and clinical samples that have been utilized by various researchers have shown that those that abuse or use substances as an adolescent have poor outcomes in several different aspects of life (Pickrel, 2002).

Community samples have shown that substance abusing adolescents are often substance abusing adults as well and many of these individuals will continue to abuse throughout their lives (Pickrel, 2002). These juvenile offenders also maintain a strong level of criminal activity into their adult lives in many cases (Pickrel, 2002). Findings regarding the various associations between substance abuse as adolescents and functioning of mental health in adulthood are somewhat mixed. However, evidence does indicate that drug use in adolescents does predict some types of mental health problems in young adulthood (Pickrel, 2002).

The costs to society for substance abuse and the criminal activity that it often generates are also very substantial and in 1987 the cost for victims of crime that was drug-related was $5.5 billion (Pickrel, 2002). The law enforcement bill that corresponded to this cost $12.8 billion (Pickrel, 2002). Because of the significant societal and personal costs that substance abuse can have there are many resources that have devoted to coming up with treatment models and other things that can help individuals stay drug-free or get drug-free if they have already started down the wrong path (Pickrel, 2002). The evidence is suggestive of the fact that some of these efforts are paying off.

There are many promising treatment models out there today, and this is especially true of those that are family based (Pickrel, 2002). Many of these include multidimensional family therapy, multisystem family therapy, and functional family therapy (Pickrel, 2002). Some of the short-term results from these family-based treatments have been very promising but many of the trials that have involved these types of treatments have not looked beyond the twelve-month follow-up (Pickrel, 2002). There is a gap in the literature at this point and therefore longer follow-up assessments have generally been called for.

Looking at four-year outcomes of family-based treatment is one way to help bridge this gap, but even a randomized trial of multisystem therapy on four-year treatment outcomes with juvenile offenders that meet the criteria for substance dependence or substance abuse is very significant (Pickrel, 2002). Findings for treatment completion were very favorable as was the increased school or work attendance and the cost savings that were occurring because of treatment (Pickrel, 2002).

Other outcomes, however, such as those that dealt with criminal activity, mental health functioning, or substance abuse, were not as strongly favorable and did not appear to last long as those achieved in trials of multisystem therapy that dealt with juvenile offenders who did not have problems with substance abuse (Pickrel, 2002). In other words, significant treatment effects were not seen to be observed for mental health measures, drug use, or criminal behavior (Pickrel, 2002). Many of the treatment effects for substance abuse were very significant post-treatment but by the six-month follow-up they had not been maintained (Pickrel, 2002). Because of this it is important to look at long-term follow-ups to different types of treatments that have seemed mixed results in the past in order to determine whether this issue of mixed results is truly accurate.

Information regarding this issue tends to be very consistent with trials that have been done in the past at 2 1/2 and four-year follow-up intervals. Property crimes did not seem to be any lower or have any type of treatment effects in the study that was conducted but adults' arrest rates appear to have been lower overall (Pickrel, 2002). Alcohol and drug use over the long period were somewhat mixed (Pickrel, 2002). Based on the tests that were done biologically this type of therapy was based on the abstinence of marijuana in a 100% increase which was very significant and the abstinence of cocaine over a 33% increase which was not considered significant (Pickrel, 2002).

Utilizing self-report information, however, did not show any type of difference between various treatment conditions. The findings were very different from those that were obtained at post-treatment and probably reflect how unstable many of the drug-related outcomes for treatment actually are (Pickrel, 2002). It does appear that family oriented treatment that is scientifically-based can produce favorable and long-term reductions in much of the antisocial behavior that is seen among offenders who abuse substances (Pickrel, 2002). Mental health outcomes and drug-related outcomes, however, do not seem to be as favorable and research is currently underway to determine ways to adjust this so that there will be a better chance of helping more individuals in the future (Pickrel, 2002).

The literature that is reviewed in the rest of this chapter begins with a foundation of the facets of addiction. This foundation will establish the biological and environmental aspects of addiction that lean towards Erikson's Mistrust, Doubt, and Guilt areas of his first three stages. The review then goes into the area of recovery and the difference between my employment and other residential treatment facilities. Within the recovery facet are the two areas, which will lean toward repairing the Mistrust, Doubt, and Guilt of addiction.

These areas are the parenting program and the childcare program. The parenting program will teach basic parenting tools that can help the mother understand her child (ren) and tools that can help reduce parental stress. There will also be an education aspect of the parenting program where the women will learn of the negative effects of addiction with regard to biological and environmental facets. The childcare program will consist of a separate childcare facility, where the children will receive a structured and consistent childcare environment.

Addiction: Biological true addiction becomes the central organizing force around which the life of the substance-abusing individual revolves, and it affects every significant aspect of that person's functioning" (U.S. Department of Health and Human Services 1994 p.9).

Barth (1991 p.133) found that the majority of babies born perinatally exposed to drugs are exposed to more than one drug, including cocaine, PCP, heroin and alcohol. He also states that other factors such as smoking, poor prenatal care, and social stress increases the chances for complications at birth. These factors show that children who are prenatally exposed may be at a larger disadvantage as we previously thought. These factors also shed light on the difficulty of raising a child who is drug exposed. "Drug exposed infants often suffer symptoms of drug withdrawal which include irritability, tremors, abnormal sleep patterns, and feeding difficulties"(Dixon 1989 p.442).

When caring for a child who exhibits these behaviors it could lead a caregiver to increased levels of frustration and stress. "In addition to negative behavioral characteristics, drug-exposed infants are at an increased risk for health care problems which may contribute to parenting stress and child maltreatment" (Kelley 1992 p. 326). Klitsch (1994 p.96) states, "overall levels of substance use were generally lowest among women who began prenatal care in the first trimester, and highest among those who received late or no prenatal care." From the Supporting substance-abusing families: A technical assistance manual for the head start management team (1994, p. 22-23): they list the most commonly seen troublesome behaviors in prenatally substance-exposed children.

Infancy (0-15 Months)

Feeding difficulties (problems with sucking, swallowing, distractibility)

Unpredictable sleep patterns

Irritability

Avoidance of eye contact

Fine motor incoordination (unsteadiness, difficulty grasping objects)

Toddlerhood (15-36 Months)

Speech delays

Increased activity levels

Problems sustaining social interactions with caregivers

Problems with fine motor coordination and balance

Preschool (3-5 Years)

Distractibility

Impulsivity or hyperactivity

Speech and language delays, both expressive and receptive

Poor task organization and sporadic mastery of tasks

Problems with attachment and separation, especially during times of transition

Poor social skills

Delays in motor development

Addiction: Environmental

Along with biological factors, there are environmental factors of the life of a substance-abusing parent or family to consider. Lester, Freier, & LaGasse, (1995 p. 27) reports that 80% of the developmental studies of prenatal substance exposure failed to include even the broadest measurement of environment. "Biological vulnerable children, due to prenatal drug exposure who are exposed to cumulative environmental risks, may be at "double jeopardy" for poor outcomes" (Carta, Atwater, & Greenwood, McConnell, McEvoy, Williams, (2001 p. 330). If one or both parents are actively abusing substances there is an increased likelihood of the family living at the poverty level, which increases the likelihood of substandard housing, poor nutrition, and lack of access to quality medical care. "Children raised in chemically dependent families are confronted with a multitude of problems and challenges to their parents illness" (Vail-Smith p.86).

This also leads to possible abuse within the home. " addicted parents often expose their children to environments that support dysfunctional behavior and that significant numbers of their offspring use drugs and engage in delinquent behaviors" (Kolar, Brown, Heartzen & Michaelson 1994). "It is clear that long-term behavioral patterns are influenced by environmental conditions, and experience has shown that instability, disorganization, and emotional upheaval within the family environment can place a child at risk for developmental difficulties" (U.S. Department of Health and Human Services 1994 p.41) the parenting styles and family dynamics contribute to the addicted lifestyle.

Chemically dependent parents generally have poor parenting skills and experience difficulty meeting their children's needs" (Davis 1990 p.231)" When parenting is punitive, inconsistent, negative, or absent altogether the children have role models that lead to misbehavior. If the family dynamics are a single parent home this increases the parental stress on the one parent that is remaining and this increases the possibility of abuse. "Parental substance abuse frequently results in some degree of child neglect, physical abuse, sexual abuse or both" (Kelley 1989 p. 318).

Parenting education is an area that best deals with the parental stress of a single parent home or the parent new in recovery. It is easy to see how the cycle of addiction is so difficult to break. With these environmental aspects the development of Mistrust, Doubt, and Guilt could be established.

Recovery

Recovery is an opportunity for mothers to examine their lives and how their addiction has caused their lives to become unmanageable. Recovery gives these mothers a chance to bring their lives to a more manageable state. Residential recovery provides one of the most important aspects of this early recovery process: a stable environment. "Most traditional residential substance treatment programs do not allow children to stay in the facility (Baker 2000 p. 870)." This makes our program more conducive to the family in recovery, is the fact that the mother and child are allowed in our facility. The mother and child both need a stable, structured, and consistent environment because before addiction this environment was not always possible.

With residential recovery comes guidance in the realm of a counselor. The counselor is educated in counseling of drug and alcohol addiction. The counselor provides the parent (client) the guidance and support to fully explore the consequences of their addiction on their lives and the lives of those around them. Nelson-Zlupko, Dore, Kauffman, & Kaltenbach, (1996 p. 55) recommend a treatment orientation that empowers women, focuses on role models for women, teaches women how to be assertive, and raises their self-esteem. Along with these guidelines, a counselor's job is to provide education on the client's addiction. Other important education in the early recovery process is life skills, vocational rehabilitation, and parenting classes. It is essential to look at the life of a substance-abusing parent or family to better understand how to meet their needs when in recovery.

Parenting Program

The parenting program focuses on new ways of parenting, other than the ones the parent was using before recovery. Providing the parent with other tools or strategies that can have a more beneficial outcome to the children is vital to the program. Certain tools revolve around education for Erikson's stage of child development. Within these stages the mother will receive education regarding her role in the acquiring, Trust, Autonomy, and Initiative. "From the mother's side of the interaction, there must also be trust-trust in herself as a parent and in the meaningfulness of her caretaking role" (Miller 1999, p. 162). This trust within is an important aspect to gain because most of these women are coming from situations where they are receiving feedback to the contrary.

Another aspect that will be taught will be creating an environment that is conducive to these stages. "Ideally, parents create a supportive atmosphere in which the child can develop a sense of self-control without a loss of self-esteem" (Miller 1999, p. 162). Overall education on the effects of prenatal exposure and environmental risks help the women in understanding what they may be facing with their children. Some education will be around the Fetal Alcohol Syndrome (FAS). Brown, Coles, & Smith (1991 p. 372) states, exposure to increasing amounts of alcohol across pregnancy has a detrimental effect on both child attention and other problem behaviors.

Teaching the parents the importance of taking care of themselves, being consistent, following through, focusing on the positive, and providing a daily routine with structure are all tools that can bring some stability to their often chaotic life. Developing an understanding with the parent that the lifestyle that they once had was not what they, nor their child needed. However, establishing these tools in their lives can make a difference to them and their children. When working with the parent new to recovery it is important for them to understand the negative consequences of their addiction on their children's lives.

Understanding how parenting is linked to substance exposure and environmental risk will assist clinicians in developing interventions that may interrupt the downward trajectories experienced by high risk children" (Carta et al. 2001 p. 331). Once the parent can understand these consequences they can begin to focus on how to correct these deficient areas. The mother is not the only one to focus on; there are also the children who need to be addressed. It is important to provide the children with the same structure and guidance the mother is getting.

Childcare Program

Being able to have a childcare program at the treatment center allows the women an opportunity many treatment facilities do not have. Baker (2000 p. 870) found that childcare was a barrier to treatment, and being able to bring their children to treatment allowed women the opportunity to discover new things about their children. When creating a childcare curriculum for women who are recovering from addiction, it is important to take into consideration the needs of the child. "They need as much consistency of personnel as possible, a dependable family life, assistance in making transitions from activity to activity, interventions to teach social problem solving, and help focusing on the task at hand" (Barth 1991 p. 134).

This child has possibly been prenatally exposed to drugs or alcohol, and is coming from the environment of a chaotic home due to the lifestyle of a drug and alcohol addicted family. The curriculum needs of this child are in the areas of environment, transitions, activities which inspire the desired behavior and extra time with them, a stable and caring teaching staff, and a low ratio of children to teacher. With consistency within these areas of curriculum these children increase the skills needed to improve their behavior.

Creating the environment for the childcare room starts with creativity in manipulating the physical environment to encourage the children toward the desired behavior. "Some children also find it hard to deal with smells or bright lights or colors" (Kaiser & Rasminsky 1999 p. 17). Noise in general should be limited to the activities at hand, because eliminating loud music, or unneeded noise will help the children concentrate on the activities they are involved in. Placing bookcases and furniture in certain areas of the room can diminish running and aggressive behavior. Eliminating all weapon-like toys, games which inspire competitiveness, and action figures may also lead to less aggressive behaviors. Slaby, Roedell, Arezzo, & Hendrix (1995 p. 36-37) state that "competitive games, violent toys and playing violent roles incite aggressive behavior." Lastly, by limiting the choices the children have and the toys, which may be played with, one limits the opportunity of disharmony.

Harmony is a goal and with the use of transition harmony can be attained. "Blinded aspects of spontaneous play behavior have suggested that children prenatally exposed to drugs, cocaine, and polychlorinated biphenyls had more immature play strategies, reduced attention, and more abrupt transitions" (Beckwith, Rodning, Norris, Phillipsen, Khandabi, & Howard 1994 p. 195). Transitions allow children the opportunity to know that one activity is about to end and when its time to start another. Transitions may start with the teacher stating, "There is five more minutes of play-doh time" this proceeds with four more minutes, and so on. When time is up it may work best to have a clean up type song for the children to sing to allow them to be fun participants in the clean up process. Use transitions from one activity to another, this will allow the children to know what is coming next. Consistency in transitions allows the child to repair the trust which may have been damaged due to addiction.

Choosing the activities in which the children are to be learning from takes time and effort on the teacher's part. By presenting children's play stations attractively it encourages the child to play with it. The play stations should also encourage language, thinking, and social development. These are to be planned out in advance and presented in a way to give the child the opportunity to use them to learn. The teacher is the guide. The Supporting substance-abusing families: A technical assistance manual for the head start management team (1994, p.45) give a few strategies for working with this population:

Provide daily opportunities for children to practice activities of daily living. Allow them to be messy and take their time. Provide opportunities for children to play interactively in a safe environment, with an adult available to support and encourage them. Provide daily opportunities for children to make small decisions and limited choices in play and/or activities of daily living.

The child needs time to play at the play stations and to learn "how to" with limited teacher interference. Guidance and supervision are encouraged, however doing the activity for the child is not. By allowing the child the opportunity to play and explore an activity until they have completed it allows them the chance to feel successful. With a child feeling success after activities this allows a child to repair the autonomy which may have been damaged due to addiction.

Children will mimic or take on the behaviors and attitudes of the adults around them. Carta et al. (2001 p. 329) states, children's daily interactions with adults place them on successful or unsuccessful developmental pathways that are difficult to change without intervention. This is why it is important to have a stable, caring teaching staff to work with these children. These children are accustomed to unstable environments and people, so by providing them with a stable caring teacher we are providing this child with the role model they need most. By creating a loving relationship with a child that is based on trust and honesty we provide these children the chance to grow and to be a child. Kaiser & Rasminsky (1999 p. 22) state a few tools childcare workers can use to help children: State the positive first, use language that empowers the child, pose choices that give the child control over the situation, allow the child time to think about what he wants to do, be consistent, follow through, be respectful of the child and of yourself and recognize the child's feelings.

Along with this relationship with the child it is important to provide the lowest ratio of children to teachers as possible. By reducing the size of the ratio this allows more one-on-one time with each child and reduces the possibility of any undesired behavior. The teacher's, more on-on-one time, and low ratios all contribute to the likelihood this child will feel successful. "We also know that children who are reared in organized, supportive, and nurturing environments tend to perform better at school and develop healthier relationships with other persons later in life" (U.S. Department of Health and Human Services 1994 p.41). These techniques allow the childcare worker to establish a relationship which helps a child to regain trust which may have been damaged due to addiction.

Parental Involvement

Many of the parents that are addicted to drugs and alcohol have problems relating to their children and being involved in their lives. In order to have a clearer understanding of how the lack of parental involvement can specifically cause problems in school and in later life it becomes necessary to look at some facts and figures that have come out in other research into the subject. This literature review should show two things. First, children need their parents or another caring adult to be involved in their lives if they are going to succeed in school. Second, the problems that children have in school extend into their later years and create difficulty with adult tasks such as maintaining a household, holding down a job, and forming good quality relationships with others.

Studies would seem to indicate that many parents realize the involvement they have in a child's life is very important, but they often do not take the time to correct this problem. In 2002, a survey taken indicated that 93% of parents believe that they should be involved with their children and the schools (St. Pierre & Layzer, 1998). However, 26% participated in parent teacher organizations, and only 32% chose to volunteer at the school on some level (Beck, 2002). It is true that many parents work and are not able to volunteer, but it still seems that this was an exceedingly low number given the amount of parents who showed concern. Parental involvement also affects children in different ways.

When parents are involved with children at school this generally affects their grades. Involvement at home generally affects test scores (MacNaughton, 1999). This indicates an area that obviously needs more research. The study that produced this information also showed that there was a difference in the involvement of the parent based on race and ethnicity. It appears that white parents spend more time with their children on school related activities than black parents on average (Catsambis, 1995). A study from 1992 indicated that many students do not believe their parents are preparing them for school. It showed that 14% of juniors and seniors in high school believed that their parents had prepared them for school and many are concerned about college and the future because of this (Mantzicopoulos, 2003).

These children have learned from an early age that they need to follow rules and take more responsibility but their lack of parental involvement is affecting them in their junior and senior years in high school and will likely continue to affect them later in life as well (White, 1994). There have been many studies conducted into this matter over the years and basically they all indicate the same thing. Parental involvement equals better school performance for the children (Garcia, 2002). Because of this, the schools are trying to get more parents to become involved but they must address something else as well. Studies have indicated that it is not only the involvement of the parent but what type of involvement the parent shows in a child's life that shapes how well they do (Paulson & Sputa, 1996).

Apparently, parents who become involved in the students life do not always agree with the students as to how much involvement they actually have (Anderson, 2000). Many parents believe that they are doing more than they actually are to help their children out and in order to correct this they must be made aware of it. Many studies also indicate that how children are brought up affects their school performance and parents that are warm and nurturing will get greatly different response from their children than those that are cold and indifferent (Vinovskis, 1993). Not only does this hold true for the child's school but also for their interest in issues such as standardized testing (Grossman, 1999).

Students, especially as they get older, change their opinions about school often through no fault of their parents. However, students that were raised around loving and concerned parents are less likely to become disenchanted with school and have problems in it compared to those that do not get the parental involvement they need. This would be indicative of the fact that what happens to children at a very young age will shape how they feel about many things as they get older (Pattnaik, 2003). Studies have also shown, however, that the involvement that a parent has in the life of a child should decrease as the child gets older (Winner & Hetland, 2003). Children must learn some things on their own if they are going to grow to be adults. This does not mean that these parents should make a specific effort to do less for their children every school year, but it does indicate that the first years of the child's education are the most important (Vadasy, Jenkins, Antil, Wayne, and O'Connor, 1997). Children will learn to do better for themselves as they grow as a result of the good parenting that they receive during the early years (Forgione, 1998).

Parental involvement can obviously be seen to be highly important. Most studies have indicated that it is a strongly important factor in a student's life and that it is one of the most important issues that a parent will have to deal with. As children get older, parents will be able to do somewhat less for them and allow them to make their own way in the world and grow into adults. However, children who are very young, even if they seem mature and intelligent, still need nurturing and love that only their parents can provide them. Children that do not get this often do not do as well on many issues and school is only one of the concerns that they will have later in life if they do not have nurturing and love early on.

The Work of Chasnoff

Even though much of the information that the literature review and the rest of the study is based on comes from the work of Erikson, there are two others that are worthy of discussion here. The first is Dr. Ira Chasnoff, who will be discussed in this section, and the second is Albert Bandura, whose Social Learning Theory will be discussed in the next section. Both of these individuals have provided interesting insight into many different facets of life, and due to this their work is significant here in understanding addictive behavior and what it can mean for the family.

In 1985, the concern about children that were born to drug-dependent mothers really became overwhelming, and this was due to the fact that the media had become aware of a study written by Chasnoff that indicated that prenatal exposure to cocaine could be very devastating for infants (Blake, 2004). There were only 23 women in the study and Chasnoff indicated that more researcher into the issue would be necessary, but the indications that there could be problems for these children was very clear (Blake, 2004). Chasnoff also has much concern for children that are acquired through international adoption, because many of them have problems that can relate to drug and alcohol abuse (Working & Madhani, 2003).

Chasnoff has done so much work in the past on babies that were born addicted to drugs that he often speaks at conferences regarding the issue and whether substance abuse by the parents is a form of child abuse (Adelman-Padilla, 2002; Anderson, 2004). As far back as 1988, Chasnoff determined that approximately 11% of 155,000 mothers surveyed at 36 hospitals in the United States had exposed their children to drugs in utero (Langone, 1988). Many of these women did not drink alcohol or smoke cigarettes during their pregnancies, but they were unable to refrain from using cocaine and other illegal drugs. Women that use cocaine during their pregnancy, Chasnoff found, also have approximately a 38% risk of miscarriage, which is much higher than the average risk for women that do not use drugs during pregnancy (Wallis, 1986).

Chasnoff is also concerned with the fact that mothers are punished when their babies are born addicted to cocaine or other substances. This is not to say that there should be no punishment for harming these infants, but only that those that most need help to kick their habit are afraid to seek help because they fear the punishment that they might face (Sachs, 1989). Because these women know that they could be punished and lose their children, they often choose not to do anything about their drug use and therefore they end up harming the children that they are, in essence, trying to protect.

When children are born addicted to drugs or alcohol, there are steps that can and must be taken to ensure that they have the best chance of living a normal life, since they do not respond the same way that a normal baby would in their first few months of life (Gardner, 1991). Some of Chasnoff's studies indicate that, by the time these children reach 3 years of age, they are generally normal in their intelligence and basic functioning (Rafferty, 1994; Toufexis, 1991; Hicks, 1994). However, they can have behavioral problems around others that will give them trouble in school in later years, and therefore early and continued intervention is necessary to protect these children and the other children that they will come into contact with when they begin school (Hicks, 1994).

In recent years, however, Chasnoff has changed his thinking somewhat, as he has become concerned that he is causing more harm than good for the mothers and children that he is trying to protect. In 1992 he stated that most babies that are born to crack-addicted mothers grow up to be perfectly normal and therefore they should not be stigmatized as unintelligent and behaviorally difficult (Begley, 1997; Logan, 1999). He has also come to the defense of single mothers, especially those that are low-income and black or another minority race. They, and their children, have been strongly stereotyped as being the worst drug abusers and mistreating their children, and therefore the children have also gained the stereotype of not being worth much, which is something that Chasnoff feels needs to be changed (Karp, 2001).

Bandura's Social Learning Theory

Another important individual when it comes to this issue is Albert Bandura, but the discussion of his work will be rather brief, since there is not that much that needs to be said about him. While he did not deal with substance abuse and recovery when it came to parenting, he did give some insight into the idea behind why people become addicts with his social learning theory. Bandura's Social Learning Theory helped to create the basis of addictive behavior theory, as it indicated that the addictive behaviors were learned behaviors (Malcolm, 2004; Turner, 2002; Beau, 2001). If they could be learned, then it seems only logical that they could be 'un-learned.'

Social learning theory has also been used to discuss the aggression and other poor-judgment actions that often come with the abuse of alcohol (Zucker, 2003; Cronce, 2001). This is one of the reasons that social-emotional curricula is so very important for young children, especially those that were born to parents that abuse drugs and alcohol or that still abuse drugs and alcohol (Strain, 2003; Botvin, 2000). A parenting program includes both the addicted parents and the children while recovery is taking place could go quite far in using Bandura's Social Learning Theory to show that there are ways to un-learn the addictive behaviors and poor parenting behaviors that have been taking place. This Social Learning Theory is part of the rationale and the theory behind such a program and behind other programs already in place to help individuals conquer drugs and alcohol.

Chapter Three

Methodology

Research Design and Approach

The methodology of any study is particularly important. Without a clear understanding of how the study was conducted and what was dealt with in it, it becomes very difficult to analyze data in a way that makes any kind of sense later on. Because of this, the methodology that is carried out must be explained clearly and precisely, so that there is no confusion about what was done, and what was discovered. The methodology for this particular study will be discussed in this chapter, and the results of the study will be detailed and conclusions drawn in the following chapter.

This section of the methodology deals specifically with how the research was designed and what approach was utilized. The approach to this particular study is considered to be really a relatively simple one, but it is also a very important one, and it makes the most sense for the information that is available and the answers that the researcher seeks to find in this particular study. Re-examining everything that has been done in the past when it comes to the literature review and drawing conclusions from it is very important, and it is still a very common and accepted way to make a determination as to what has been discovered in any particular study. This was the approach chosen here, but experience also comes from the knowledge and background of the researcher, having first-hand experience with this issue regarding substance abuse where parents are concerned and the problems that are often caused by it.

The collected data of others will be utilized in order to determine what kind of information has been seen in the past and whether the current study indicates the same types of concerns. This is important, since there may be different, and new, information that is presented from the data that the researcher has from first-hand knowledge of the problem. This type of analysis can allow for better understanding of what has gone on in the past, what the current study shows, and where future trends are heading when it comes to this very important issue. This also allows a framework and a basis by which the researcher can then create the parenting program (see Appendix).

While many studies interview subjects or conduct surveys, analyzing and reviewing the work of others is still quite a common method for many researchers to use when conducting a study of this nature, which is why it will be done for help in understanding what has gone before where research into parenting and substance abuse is concerned. Knowledge of those that have actually been through this ordeal and/or may have this problem is vital, however, to an understanding of what is really happening with parents and their substance abuse and recovery, and how it can be changed through the use of better understandings of both parenting skills and the problems that many individuals with substance abuse face.

This is especially true for a subject such as this where there is so much information available in articles and studies, and when that information goes back so far, since helping to find ways to help these individuals, and helping to understand what their problems really are and where they come from is something that the literature review is especially good for. This issue has been studied for many years, although not as strongly from the context of parenting, and this provides a wealth of information that deals with the issue and those smaller issues that surround it. Were it not for this information, it would be necessary to conduct a costly and time consuming method of study that would provide enough data for the current research, in addition to the knowledge that the researcher already had regarding this issue. Since there is so much relevant information already available when it comes to substance abuse and recovery, however, this will not be necessary.

An approach such as this one showcases the information that was collected by others in the literature review and also allows the researcher's knowledge and information to be examined and studied in a way that might be different from the ways that other researchers would utilize it or from the ways that similar information has already been presented in articles and other studies, thus broadening the issue and the understanding of the information provided.

It is for this reason that the researcher has chosen to use this particular method when it comes to this study of substance abuse and recovery where parenting is concerned. The information is already there when it comes to what substance abuse really is and how being a parent, especially of young children or many children, can compound the problem, but the way that it is presented and what can be done to show what it really means can always be looked at and changed in some way that helps to clarify what was originally said and what the researcher is trying to show in the current study.

Much of this is done by using the knowledge and information that the researcher already has and that relates specifically to parenting, and the drug and alcohol use and abuse recovery that may make parenting more difficult and therefore harm the children as well. This not only showcases the information that is already available, but also indicates the importance of the work done by the researcher in the form of the parenting program (see Appendix), and presents it all in such a way as to bring new consideration to what is being examined.

This is an important aspect of the study because information about parenting and the concept of drug and alcohol abuse and what it can do to people and families all must be presented before the data is discussed and before any conclusions are drawn. This was largely the purpose of the extensive review of the literature. Although most of the literature review deals with substance use and abuse in general, there are also implications about parents specifically that need to be discussed and therefore the information that was collected is very valuable.

Not all approaches work well for all studies, and care must be taken to ensure that the proper approach is utilized so that the study will be the best that it can be and make the most sense for all involved who read it. It is also important that the study impart the information that it is designed for, so that it will answer the question that was really asked. While there is no reason to assume that this is the only approach that will work, it is reasonable to assume that it is one of few approaches that will work, and that trying to utilize too many approaches or working with one that would be unfamiliar to the researcher would be difficult and would result in problems with the rest of the study.

Population and Sample

The database for the study will be relatively large, simply because there is so much information available in the literature that has been collected. Approximately 80 articles and studies that dealt with this subject were consulted and used in the literature review so that information about substance abuse and parenting that is seen in the analysis can be backed up by sound theory and information. By doing this, the database will be much larger than it would have otherwise been, and it will also provide much more information than the researcher might have collected simply on his or her own.

Surveying those that are involved in the recovery from drug or alcohol abuse could be done, but there are potential problems with this method. Some of this comes from the sheer volume of information that could be compiled, and some of it comes from the fact that the researcher could potentially forget to ask a particular question that might be important later, or could possibly word something in such a way that it would be misinterpreted and therefore not provide the researcher with the information that is really needed to deal with the problem statement that was presented earlier. This is one of the main dangers with surveys, as there are always mistakes that could be made or issues that could be problematic when the wrong questions are asked, or even when the right questions are asked in the wrong way.

This is in no way indicative of the idea that surveys are not appropriate for this kind of study or that there is some problem with them. They are very valuable when it comes to collecting specific information about substance abuse and recovery. However, for this particular study, the knowledge and information that the researcher already has from first-hand experience has been supplemented, when it comes to substance abuse and parenting, by information that has already been collected and compiled from the research that has been done by others. This is vital because there is so much information that is relevant to substance abuse and recovery, and it deals with much more than just parenting.

The number of articles and studies that have been utilized is relatively large, and this allows for a lot of pertinent information when it comes to parenting and how substance abuse affects them and their children. Information of this type is supplemented quite easily by what has been seen in the researcher's own work. By using this larger database of studies in addition to the knowledge of the researcher, a much more complete picture of the issue can be created and the information that the researcher uses can be considered to be sufficient to provide understanding and answers for the study regarding parenting when it comes to this issue of drug and alcohol abuse and recovery.

As to the validity of the data, it would appear that information contained in studies that were written specifically about this subject would be considered to be valid. The information that was collected from first-hand experience by the researcher is also considered valid, since it is specific to this study and new to the issue. Since the studies are not works of fiction, they are assumed to be genuine information that has been legitimately acquired and verified. It would not be possible, however, for this researcher to verify everything that is read in these studies to ensure that it was accurate, just as it would not be possible for the researcher to prove that no one lied when talking to the researcher in the past.

Due to this, the assumption must be made that the authors of these studies wrote what was genuine and accurate, and that they did not cut corners or create something that they knew was not actually as truthful as it could have been. There is always the possibility that honest mistakes were innocently made, and these cannot be helped. The same is true for the work that was done by the researcher, since there is always the possibility of mistakes or problems, and there is always the possibility that those that were examined and questioned during work experience in the past did not answer truthfully. This possibility with the researcher's experience and the information collected for the literature review is rather remote and does not in any way discount the work that was done by the researcher or the information that was collected here for this study.

The data, however, is valid for this particular study because it deals with the subject of drug and alcohol abuse and recovery and parenting in a way that is assumed to be factual, and because the studies that have been used are dealing with the subject that the researcher wishes to address, as is the work experience that the researcher has acquired. In other words, they are the kind of studies, knowledge, and informational writings that one would expect the researcher to use when considering this issue and therefore deal with the same information that this particular study looks at.

Since the data regarding substance abuse itself comes from studies done by others, it is not original to this study. In other words, it was not been created specifically for this particular study. However, the data is original in the fact that it is being presented and analyzed in an original way. That gives some originality, if not specifically to the data, at least to the study. Creating original data on substance abuse in general would be a time consuming and costly process, and would also be largely unnecessary when there is so much other information that is already available and could be used for this study.

The researcher's own first-hand knowledge, however, is original to this study, as there is information that was collected by the researcher during work experience that did not come from the work of others. This knowledge has not been used for any previous study and therefore it contains completely original information that is utilized only for this study by the researcher. This lends a lot of credibility and originality to the study in the form of the data on parenting, which has not been studied in this way before to the best of the researcher's knowledge. Without this, the study would only deal with what had already been done by other researchers when it comes to substance abuse and recovery in general, and the parenting angle would have largely been ignored or discounted in some way.

Collection and Tabulation of Data

Because of the approach to this particular study, the method that will be used to gather the data will consist of an analysis of the information that was presented in the literature review regarding substance abuse and information collected from the researcher's knowledge into the current state of parenting where that issue is concerned. All of the information found in the literature review articles could not possibly be incorporated into the literature review, but a great deal of it is in there. Other information that was read and understood but was not able to fit into the literature review will also be used in determining the answers that will be incorporated into the data discussion, conclusions, and recommendations that will take place in Chapter Four, although enough new information will not be introduced to confuse or upset the reader in any way.

The researcher's own knowledge will also be incorporated into the findings in Chapter Four, as it is vital to a complete understanding of the information that is presented about substance abuse and recovery and what should be the best plan of action for parents, since few parents seem to realize how important and significant what they do in their own lives is when it comes to their children, as well as how debilitating and harmful substance abuse can be if it is left untreated.

When collecting the data, however, the articles that were used for the literature review will be carefully examined so that any pertinent information is not only included in the literature review but also compiled for use in the last chapter. This is necessary, because there is so much information available on the subject, and because the information goes back in time such a long way. Using only what would fit in the literature review would not really do justice to the issue at hand and would only touch the surface. The literature review information and the researcher's personal knowledge information will be coupled in such a way that the importance of substance abuse recovery as it relates to parenting can be seen.

While this may seem like a simple way to gather data, the sheer volume of information that must be sifted through and considered makes the process somewhat time consuming. Not as time consuming, however, as utilizing only surveys or other ways of gaining information, which can take much longer while the researcher compiles them, makes sure they are appropriate and will provide the necessary information, and then attempts to have them answered. If this technique was employed for substance abuse in general the whole process would soon become much too large of an undertaking.

This is due to the fact that, often, very few of the surveys are actually completed and returned, and this makes the process of collecting enough information rather difficult. With the information as to substance abuse and recovery where parenting is concerned this is terribly problematic. This information is best compiled from what others already know and from the knowledge of the researcher, which is why the literature review was chosen for this particular purpose over surveys or other methods.

By using data that has been previously collected elsewhere and compiling it for the purpose and intent of the information in this study, the researcher carefully avoids all of the problems that can come from surveys that do not ask the right questions and from individuals who are unwilling to participate and return the surveys that have been sent to them. The time is shorter when the data from the literature review is used, and the amount of information is much larger than what could have been collected by any other realistic means. Naturally, however, there is little that has been written about parenting specifically when it comes to substance abuse and recovery, and therefore the researcher's knowledge and understanding into this issue were deemed necessary. Another reason that this was deemed necessary was to see whether substance abuse and recovery problems have changed any as society has changed, or whether the same problems and issues are still being dealt with.

The literature review is also wonderful for gathering data from because the studies that are used provide so much information and are so repetitious in what they have to say. In other words, many of them confirm what others say and so it makes sense to look at these studies as an important collection of what has been said about this subject and what will likely continue to be said well into the future. It will be of interest to see whether the current study's finding have that same sort of repetition when compared to substance abuse and recovery studies that deal with parenting or the effects on children to some extent.

Data Analysis Procedure

The data analysis will use information that has already been collected by others that have written books and articles about the subject at hand, or about parts of the subject that work to make up the whole substance abuse and recovery where parenting is concerned, as well as information that has been collected by the researcher. The information from the literature will generally consist of a great deal of information from articles, but information from other sources will also be used to provide some of the data that is so important to the study. This is done for several reasons, but the two most significant ones are time and cost. Attempting to collect new data about substance abuse and recovery overall would be costly, and it would also take up a great deal of time that could be better spent.

Another reason for the use of previously collected material for substance abuse and recovery is that it is often very difficult to get individuals to talk about the issue. With some individuals that wish to share their stories and help others it is sometimes easier, but those that have spent a great deal of time dealing with pain and degradation often have a hard time discussing it and their feelings toward it with a stranger, or getting those feelings down on paper. Some of this comes from the guilt and the shame that these victims feel - that it was somehow 'their fault' and that they should have known better, or that they are weak individuals that could not control themselves. With this in mind, just collecting data through surveys or interviews could prove very difficult and upsetting, and delay the study for quite some time. In an effort to avoid this problem, the researcher has chosen to utilize the material of others that have already been published, giving credit where it is due, and use that information in a way that is unique to the study based on qualitative analysis.

This does not mean that the literature that was reviewed will be the main focus of the data discussion conducted in Chapter Four. The main focus will always be on the parenting angle and the information that belongs to the researcher's knowledge base. However, some information from the literature and studies of others can be mentioned and incorporated in the discussion of the information to back up claims made by the researcher or to tie information together more clearly.

One advantage to doing this is that the database for the study is quite large. This is due to the fact that there are so many books and articles published about the issue overall. Not all of them are studies, but they still contain a great deal of information, and that information can then be used by the researcher, coupled with the work that the researcher has done, to create a study that examines the issue of substance abuse and recovery with specific insight into parenting and how the issue affects children, as well as whether parents benefit from residential treatment where their children are allowed to be present during recovery.

Studies must have something new to present, and if the data that they use is not original, they must present something new and important in some other way, such as the way that the information is examined. The information that was collected by the researcher through working with these individuals as well as the information that was taken from the literature review dealing with substance abuse and recovery overall give both new information and stability to the study.

In the following chapter, the information will be discussed and studied so that a determination can be made as to whether the problem statement is a valid one, whether it must be adjusted to be valid, or whether further study into the issue is needed. This is the most important thing that will be done in this study, and a thorough understanding of how this will be carried out is very important to ensure that the reader is aware of what is being done and whether there has been success at the completion of the study.

Studies often end by being uncertain as to whether the problem statement is valid or whether the question asked has truly been answered. This study is likely no exception to this rule, but every effort has been made to see that the study is as clear as possible and that it validates or invalidates the problem statement as much as it is able to with the information collected. The study will also culminate with a parenting program (See Appendix) of the researcher's own devising, that has been created based on information collected in the literature review and knowledge gained by the researcher through work experience with individuals in substance abuse treatment programs.

Chapter Four

Discussion, Recommendations, and Conclusions

Discussing the data is a significant part of any study. Without doing this, there is little that can be learned from the data collected. The methodology discussed in the previous chapter gives a great deal of insight into how the data was collected. The information presented in this chapter will show all of this data and will discuss it thoroughly, so that there will be no question of understanding what was collected, where it came from, and how it explains substance abuse and recovery as it relates to parenting.

When analyzing the data for studies such as this it is often somewhat difficult because qualitative studies do not lend themselves quite as easy to an analysis of the data as those of a more quantitative nature do. Much of this has to do with the fact that there is no specific statistical analysis that can be utilized for studies of this kind. However, analyzing the data is a part of any type of study and therefore it is very important that the best analysis of the given and collected data possible be conducted based on qualitative means.

Discussion

In summary, it can be seen that the problem of drug and alcohol abuse is a large one. There are many adolescents that have been through detox and other treatment programs, and many more that probably should be, and there are many parents that have contributed to this problem by engaging in this type of behavior as well. Also, there are a large number of individuals that have been through these kinds of programs more than once, which means that they did not get what they needed to stay clean and sober the first time around. This is frustrating for those that work to help these people, since they are made to feel as though they are not doing all that they could or should be for these individuals if they are returning for more treatment in the future.

The information collected and presented in the literature review serves as background and reinforcement to what is seen in this chapter and what will be seen in the parenting program. This is significant because it indicates that the current statistics and information that are seen regarding drug and alcohol abuse fall in line with what has been seen in the past, as well. While there are likely more individuals in drug and alcohol treatment centers today, this does not mean that there are more individuals using these substances. Studies into this issue conflict as to whether the rate of usage for alcohol and drugs among adolescents is actually going up, or whether there are simply more adolescents today and therefore the numbers seem to be larger. One thing is certain, however, and that is that parents that abuse drugs and alcohol often create children and adolescents that do the same. This being the case, the parents are the ones that should be strongly targeted if they are to stay clean and sober and raise another generation that will avoid the pitfalls of drugs and alcohol.

Either way, more individuals are seeking treatment for their alcohol and drug problems, and this is encouraging. It means that these people are realizing that they need help, or at least that the court system is realizing that they need help and therefore forcing them into treatment programs. Other studies have shown, and this study has also shown, that individuals often do better when they are not forced into treatment, however, and the focus should therefore be on finding ways to encourage these people to seek treatment on their own. This should result in lower recidivism rates and a higher number of individuals that are able to stay clean and sober once their treatment has been completed.

Parents must spend time with their children in order for those children to form strong bonds with the family and in order for those children to feel secure and safe. Parents that are addicted to drugs and alcohol are often unable to spend this kind of time with their children and therefore the close ties and family bonds that would normally be formed are not present. Unfortunately, the parents may not realize that this is taking place because of the altered state that they are in when they abuse alcohol and other drugs. By the time the parents realize, if they ever do, that there is a problem, the children may be lost to them to some degree because many of these parents still will not know how to get help and even the ones that do get help may have waited too long for their children to ever really connect with them again.

This is unfortunate, and it not only hurts the parents but hurts the children as well. Naturally, avoidance of drugs and/or alcohol by the parents would be the best choice. However, many parents are already headed down the road that leads to use or abuse of these substances. It is these parents that the parenting program in the Appendix will focus on. The program is a 10-week parenting program for women and their children and is designed around residential treatment. It stems from the information collected in the literature review in this study and also from the personal knowledge and experience of the researcher who has witnessed various types of residential treatment programs some that have allowed children to be present and some that have not.

Through an analysis of the information collected and through personal experience it is believed that having children present and teaching parents how to handle these children in addition to how to recover from their addiction will make them much better parents. The information collected in this study also indicates quite strongly that there are many adolescents that have been involved in drug treatment or will be involved in drug treatment in the future. This is an indication that, not only are parents failing their children, but the children see the addictive and substanceabusive behavior as being normal. Parents must be taught how to remain clean and sober and how to correctly care for their children if the children are to grow up clean and sober as well.

Of course, there are exceptions to this rule. There are good households with strong and loving parents that produce children that become addicted to drugs and alcohol. There are also drug and alcohol addicted parents that produce children that are nothing but clean and sober throughout their lives. Evidence would indicate, however, that these appear to be the exception to the rule and that generally parents that are addicted to drugs and alcohol either during pregnancy or after it will produce children that become addicted to drugs and alcohol at some point during their lives. This is even more problematic for individuals that had no choice because their mother used drugs or alcohol while she was pregnant with them.

Recommendations

Recommendations for future research are relatively brief, since so much has already been covered in past research. However, one recommendation would be that a study similar to this one be conducted with a group of individuals, and presumably with a group of post-treatment individuals that have been out of treatment for a longer period of time to determine how they are faring. This would help to study the recidivism rate for a longer period of time, which might provide more indication about the length of time these individuals abstain, on average, before they return to drugs or alcohol if they are going to. This could help those that work with these people on this problem to find ways in which they could intervene of schedule follow-up appointments for these individuals in an effort to keep them on the right path.

It is not always easy to remain on the path that one knows to be correct, and these individuals are faced with many pressures. Another area for future research would be to study those that do relapse and determine why it occurred. Were they bored? Did they succumb to peer pressure? Did their parents abuse drugs or alcohol? There could be countless other reasons as well, and until these reasons are studied and understood, there is little that can be done to help these individuals when it comes to what makes them give in and go back to drugs and alcohol. Because of this, the understanding of this area is one of great importance for many researchers and should be looked into in the future.

The most significant recommendation that can be made, however, is that parenting programs like the one discussed here in the Appendix should be utilized more often to teach parents how to take care of their children properly and how to remain clean and sober while they do so. This is important to the health and well-being of the parents, but more important to the health and well-being of the children, as young children cannot take care of themselves and often view their parents behavior as the correct behavior. Until these parents are capable of teaching their children right from wrong when it comes to drugs and alcohol, it will always be a struggle for these children to make it.

Parenting programs, naturally, are designed to help parents take better care of their children and be better at their job. However, it is important to note that these types of programs not only benefit the parents, but the children as well. When children have good homes and loving parents, they tend to thrive. Not only do they often avoid the pitfalls of drugs and alcohol, but they also tend to do better in school, have better attitudes about life, and generally be more agreeable overall. Once again, there are exceptions to every rule, but generally this appears to be the case.

The main reason that parenting programs such as the one discussed in the Appendix are so important is that many parents that are drug and alcohol addicted do not know where to turn for parenting help. They make get help to handle their addiction and they may be in recovery but the stress and strain of taking care of even one child can sometimes push these individuals back to drugs and alcohol. Parents must see their children not as a burden but as a gift, and even though many parents already see their children in this way, there is help and support available for those that do not. Whether this is due to the fact that the mother is very young, whether it is due to being a single parent, or whether it is due to abuse or some other issue, there are always steps that can be taken in order to help parents feel better about themselves and also about their children. This is where the parenting program comes in and why it is recommended so strongly to help these individuals.

Conclusions

Those that are parents and struggling with drug and alcohol abuse still have many needs, and they do not often understand everything in the way that they should to remain clean and sober, especially when it comes to what they are doing to their children. When their children come from homes where there is alcohol and drug abuse, this simply makes it easier for them to obtain these kinds of things. This does not mean that all children that come from these kinds of homes will involve themselves with drugs and alcohol, nor does it mean that they will not be able to remain clean if they seek treatment. However, if they go through treatment and are put right back into an environment where there are drugs and alcohol readily available, it is not surprising that so many of them choose to go back to it.

Because of this problem, adolescents that use or abuse drugs and alcohol must overcome much more than many adults that have this problem, and making sure that their parents are clean and sober is one of the ways to help protect them. These adolescents are more susceptible to peer pressure than most adults are, and they are also often trapped in the home life that they have, because they still rely on their parents. They cannot simply get up and leave if they are placed in an uncomfortable situation, and they cannot just move away and start over somewhere else. When they are old enough, they will be able to do those things, but until then they often return to their old way of life simply because they know no other way and do not see any other options.

Some individuals are stronger than others in this, which is why not all adolescents use drugs and alcohol if their parents do, and why not all adolescents that go through treatment become involved again with drugs and alcohol when they get out. For many, though, that strength is not there, and these are the ones that have to be watched more closely, so that interventions can be started early if it appears that they are going to have a problem or are going to go back to a way of life that caused them a problem before. These adolescents represent the future of the country, and it is the job of the adults in that country to keep them safe.

When parents use or abuse drugs and alcohol, they do not keep their children safe from harm, and they often start them down a path that they should not be on. Many of them struggle with addiction all of their lives, or they begin to view that way of life as normal. It is not normal, however, and parents that are abusing drugs and alcohol are doing a great disservice to their children. Until they can become clean and stay that way, their children will continue to struggle as well, and this indicates that a parenting program that teaches parents not only how to stay clean and sober, but how to take care of and provide for their children as well, is necessary for the safety of these children.

It is very unfortunate that many parents do not realize the damage that they are doing to their children when they use or abuse drugs and alcohol. It appears, however, that most individuals that abuse substances of some kind or another generally believe that the only person that they are harming is themselves. If they are a single person living alone with no real ties to anyone else, this may be somewhat true. However, most individuals are not this way. Most have families that care for them and friends that know that these individuals need help. Even those that are single with virtually no ties to anyone else can harm others by getting drunk and getting behind the wheel or by using drugs and committing crimes, among other examples.

When parents abuse drugs and alcohol, they are in constant contact with the ones that they are hurting the most their children. Often, the parents do not know how to get out of the cycle that they have found themselves in and the children do not know how to help the parents. Sometimes the children turn to drugs and alcohol themselves, sometimes they run away, and sometimes they either end their lives or have their lives ended by someone else because of the quality of life that they live and the type of people that they and their parents tend to associate with.

All of these outcomes are tragic and unfortunate, and the parents can generally avoid these types of outcomes. However, it is not simply getting the parents clean and sober that is the answer. The parents must be taught how to do their job as parents correctly and they must learn not only how to take care of their children but how to love them and relate to them as well. There will always be times where a parent does not necessarily like something that a child has done, and there are likely parents out there that do not like themselves and therefore do not like their children either. Many individuals that are addicted to drugs and alcohol have this problem. They know that they should not do the things that they do and because they seem unable to stop themselves they get angry and unhappy with who they are and the life that they are leading. This anger and resentment can often spill over to the children as well.

When this takes place young children tend to feel unloved and unwanted by their parent or parents, and when this happens around older children many of them will either turn to drugs and alcohol themselves or will become sullen and hostile to their parents and the family environment in general. It is hoped that the 10-week parenting program that is proposed in the Appendix will help shed light on the problem and also indicate ways that parents and children can relate better to one another so that painful problems and all of the issues that can come from the abuse of drugs and alcohol can be avoided in the future.

Appendix

10-Week Parenting Program

Overview

The 10-week parenting program is designed for women and children in residential treatment. In other words, this is not an outpatient program, but an inpatient treatment idea that will allow the women who are going through their treatment and recovery to have their children present. It is believed by the researcher that women that are able to have their children present with them during treatment and recovery recover better and are more likely to stay clean and sober than others that do not have their children present. Without a program such as this for a guideline, however, it is difficult to determine whether that hypothesis holds true. The goal here is to create that parenting program and give an idea of what will be included in it.

Since the program is a 10-week program, it has been divided into 10 separate parenting classes. Each one of those classes will be discussed here so that the reader can clearly and completely understand what exactly will be taught to the parents in each one of these classes and what these parents can expect to get from the classes that they take. It is important to note that these parenting program classes will be in addition to any other classes or inpatient residential work that these women must complete in order to be released from treatment, and they will not be a substitute for anything else that will be done at the treatment center. This is important, because recovery from addiction, even when one is a parent, involves much more than simply learning how to care for a child or children properly. These women must also learn to care for themselves properly, but that is the focus of the rest of their residential treatment, and not of this program.

There are also other issues that must be addressed before the classes can be discussed, and much of this involves the why of the project and of the specific classes. VanBremen and Chasnoff (1994) also offer the following guidelines, reproduced here verbatim, to those that are wishing to create a childcare curriculum or parenting program for those that are in residential treatment for substance abuse:

1. Examine the theoretical underpinnings of the sponsoring agencies as related to parenting. Programs need to understand how different points of entry may indicate different attitudes about parenting support and education. Is the primary client the parent or the child and how does this affect the parenting intervention? Is the orientation of the lead agency addiction, education, or medical, and how do the attitudes of the lead agency shape the approach toward parenting? What are the assumptions that the staff begin with about parenting, both from the point-of-view of their disciplines and their own personal histories of parenting?

2. Address conflicts between confronting addiction and providing a nurturing atmosphere for parents. Bringing children into a treatment center requires some changes in traditional approaches to addiction treatment. Successful treatment programs will encourage new approaches that address both parenting and addiction. Successful early intervention programs will address the realities of addiction and avoid enabling behavior.

3. Provide an ongoing means by which staff from a variety of disciplines and personal backgrounds can achieve consensus on the program's approach toward parent support and education. It is not enough to provide in-service training during the start-up phase of a new program and then assume that all present and subsequent staff will espouse and practice these attitudes toward parenting. In order to achieve a consistent approach, a continuing dialogue will need to be a regular part of staff gatherings.

4. Establish priorities both for time and content of parenting interventions. There is never enough time to schedule all the activities these women and their children need. Staff need to agree on the key experiences they can provide, and on how much time to allot to these experiences within the confines of the daily schedule.

5. Understand that what happens in the hallways and cafeteria when clients, children, and staff interact may have even more of an impact on parenting than what happens in carefully planned lessons. When staff have had the opportunity to fully examine their parenting attitudes and beliefs and understand how one acquires parenting skills, they will also understand that these attitudes, beliefs, anti-skills are transmitted through ordinary human interactions, which are not specific to times or places set aside for parenting.

6. Provide for transition periods for parents in recovery. Mothers will need long, gradual transitions to independent living, particularly if termination of treatment will result in new custody responsibilities. Women in recovery romanticize what their new relationships with their children will be like, and their children may feel free for the first time to act like children, often exhibiting challenging behaviors. Frustration and relapses are almost certain without support.

7. Redefine success. Almost every addict relapses several times before achieving sobriety. Changing parenting behaviors and attitudes is a long-term process. Recognize that both treatment and parenting interventions may be planting the seeds that current staff will not see flower.

These guidelines are not completely inclusive and cannot possibly cover every issue that may arise, but they are worth consideration, especially since Dr. Chasnoff is such a leader in this particular field and has been working with substance abuse and addicted babies since the mid-1980s. The guidelines given above also provide the reader with some insight into why a particular idea is proposed or why a particular subject is decided on in such a way that it is important enough to become a class.

In addition to the 10 specific classes, however, there are other issues that will likely be incorporated into various classes when they are seen to tie in with an issue that is being discussed during that class. There are various special needs that many children have when they are born addicted to a substance and/or when they grow up in a household where drugs and alcohol are considered to be the norm. A consistent and nurturing environment for childcare will also be provided in addition to the parenting classes that are discussed here, so that these children can begin to feel a sense of stability in their lives and so that their mothers can begin to see how their children react to this nurturing treatment and the consistency that all children, especially small children, need.

The 10 Classes

Each class will be discussed here in the context of what it will offer, what the mother can expect to get from the class, and why there is so much importance placed on the particular class. There must be something worthwhile out of the classes that are taught, or the mother may turn a blind eye to the rest of the classes because of her feelings about one or more of them. To avoid this, the classes all focus on different issues, but they are also all interconnected, and it is the hope of the researcher that everything that needs to be dealt with can be handled within these 10 classes in such a way that the mother will have a much better understanding of both herself and her child so that the bond that they both need (and likely both want) can be starting to form before the mother is released.

Lifestyle of Addiction and Recovery

This first class deals with the lifestyle that the mother has led during the time that she has been addicted, and what kind of lifestyle changes have taken place where the recovery process is concerned. When a mother is addicted to drugs, alcohol, or both, there are many things that she cannot do for herself and cannot or will not do for her child. Because of this, the bonding that she should have with her child is often not present, and if it is present it is not as strong as it should be. This is, naturally, a serious concern for those that see it happening, but the mother may not even be aware of it and the child may not understand that there should be a closer bond. This can depend on whether the mother has been a substance abuser throughout the entire life of the child, or whether this is something that has only recently happened.

This particular class is designed mostly to show the differences between the lifestyle that the mother has been living while addicted and the lifestyle that the mother is living now in recovery, with emphasis on the lifestyle that the mother will want to live when the residential treatment ends and the mother is able to go her own way again. The differences in these lifestyles are very important, as a mother that does not understand and recognize these differences will often not see any significance to them, and this can lessen the chances that she will stay clean and sober once she leaves treatment.

Even though the classes are designed for parenting, the mother must be able to take care of herself before she can take care of her child, and this is why the first class will focus on this issue. Mothers that learn and understand the differences between the destructive lifestyle that they were living and the more comfortable lifestyle that they could be living will be more likely to keep that more comfortable lifestyle it gives them something to work for and something to hope for.

By using this as a first class, the mother will learn what she needs to know about taking better care of herself so that she will be better prepared to take care of her child (ren). It will also help the mother to feel less stress regarding the parenting issue, to see herself as being more capable, and to work toward a clearer understanding with her child (ren) so that she can provide for herself and for them.

Lifestyle of the Child During Addiction and Recovery of the Parent

The next class will look at what the child has had to go through during the mothers addiction and what the child might be feeling now, while the mother is in recovery. An understanding of the childs feelings is tantamount to bonding with the child and making the house that the mother and child will return to a true home. Some of the mothers are married, and some have family to help them, but many are single mothers that are basically on their own. They feel overwhelmed with life and with caring for a child or children. They do not understand, yet, that even though their child needs them, they may need their child as well, as a source of comfort and support when things get rough. This emphatically does not mean that the mother should take the less dominant role, but that the mother and child have each other and can rely on each other for love and caring.

During the addiction of the mother, many things happen to the child. Very young children do not really understand about drugs and alcohol and why they are so bad for people, but they do understand that something is wrong with mommy. Children are very intuitive, and they often understand things on some basic level that most adults assume they do not. Children can become withdrawn and jaded at the idea that the mother might actually pay attention to them or care what happens to them. Due to this, many mothers have trouble re-connecting with their children once they have made their way into recovery. This is especially true if the mother has been battling addiction for some time and has been in and out of treatment more than once. These mothers are often seen by their children as not being trustworthy and so, when the mothers are in recovery, the children are not interested in giving them a chance. They have already done this before, and it has not worked.

To understand what the child is really going through, the mother must understand this reaction and the concern that the child has that the mother will simply go back to addiction and substance abuse at some point in the future. There is no way to completely convince a child that this will not be the case, but there are ways to work with a child to show them that the mother is trying, and that she wants to stay clean. Having open and honest communication, from both the mother and the child, is one way of working through some of the problems, concerns, and fears that the child might have.

When the mother is in recovery, children that are not so jaded will hold high hopes that the mother will be all right, and that she will be able to give them all of the love and the attention that they have been craving from her. It is important that these children understand that this may not be the case, but not for reasons of substance abuse. The mother often must find work, take care of a house, and do many other things that will take her away from her children to some extent, but these will not be the same kind of away moments as those that were seen when the mother was abusing substances. The differences must be understood by the child as much as possible so that the child can feel safe again and understand that the mother is not going away to abuse drugs and alcohol but so she can make a better life for them through working, attending college classes, and attending meetings that will help her to remain clean and sober throughout the future.

Physical and Emotional Unavailability

This is one of the hardest concepts for many people to grasp, because most people assume that if the mother is physically present she is available to her children. While this may be true in some form, being emotionally unavailable is more damaging, and many mothers that are substance abusers are emotionally unavailable to their children. This comes from the effects that the drugs and alcohol have on the mind, and on the level of caring and concern that is often displayed by the mother.

Being physically unavailable implies that the mother is somewhere else where the child cannot get to her. She could be at work, in the car traveling to or from home, at the home of a friend or relative, at the store, or countless other places. As long as the child knows that the mother is coming back and the child is old enough to be left alone, there is basically no harm done. However, with mothers that are addicted to drugs or alcohol, this physical unavailability may stretch to dangerous proportions, such as being gone for long periods of time without explanation and allowing very young children to remain home alone and unsupervised. This can be very dangerous for children that are young and are not able to take care of themselves because they do not know the boundaries and rules that they should know, and the mother is not around to enforce these things to ensure their safety.

While this is certainly a dangerous byproduct of drug and alcohol abuse, being emotionally unavailable can be more damaging in the long run. When a mother is emotionally unavailable, she is often physically present, but the love, caring, compassion, and understanding that society expects mothers to have for their children is not there with her. These kinds of mother do not tuck their children in at night, hug and kiss them, tell them that they are proud of them, look at their report cards with interest, supervise their homework, or do any of the other emotional and important things that mothers that are not substance abusers generally do. When this takes place, the children can easily begin to feel as though no one cares about them and they often do not understand why they should care about themselves, either, or others that they know from school or the neighborhood.

This lack of concern by the mother, and the subsequent lack of self-concern by the child, can lead that child to destructive behaviors at home and in school which only complicates the already fragile relationship that the child has with the mother. This is not always the case, but it has been seen to be the case often enough that it warrants a discussion with these mothers that are in recovery in how to remain emotionally available for their children by talking to them and by letting the children express their own feelings, as long as they are doing it in a way that is appropriate and not damaging to anyone else. Until the mothers learn to be available for their children, the children will have no desire to open up and share the feelings that they have and the pain that they might be enduring.

If they cannot share these things with their mother when they are young, they will not learn how to share these things with others as they grow older, which can leave them cold and distant people that have trouble making friends and having a family of their own some day. If they do have a family of their own, that family may face the same problem of emotional unavailability that the child faced growing up.

The Developmental Risk to the Child

In addition to the many problems that children face when their mothers are addicted to drugs and alcohol, children that were born to mothers that used drugs and alcohol during their pregnancies can face other developmental problems. Mothers that are in recovery must understand this danger so that they can be more aware of it if they choose to have more children in the future. Mothers that stay clean and sober can certainly have more children, but the danger to the children if these mothers do not stay clean and sober is very real.

One of the most serious issues, fetal alcohol syndrome, is caused by heavy drinking during pregnancy. Physical characteristics and disabilities can be caused by this, and developmental problems accompany these physical traits. Many of these children are slow to understand new concepts and they often have IQs that are lower than normal. These children can also have trouble with speech and motor skills. There is no real way to predict whether a child will get fetal alcohol syndrome, but the more alcohol consumed during pregnancy, the higher the chances that there will be problems. This is especially true if the alcohol is consumed in large quantities. In other words, there is likely less danger in a mother having one small glass of wine every day than there is in a mother having binge-drinking problems every weekend.

When alcohol is consumed in small quantities, it can be metabolized faster by the mother and therefore less of it gets to the baby. Large amount of alcohol, however, do not metabolize as fast, and because of this the baby gets more of the alcohol. Many people do not understand this difference, and so they feel that they are safe to drink, if they only do it on the weekends. If they consume a lot of alcohol at that time, however, they are doing more harm to their baby than they likely realize.

Crack cocaine seems to be another popular drug for pregnant women, in that many babies are born addicted to it. It is the most common illegal drug that babies are born addicted to, and there are developmental problems that come from it as well. While there have been arguments both ways about whether there are long-term effects, there are definitely short-term effects that cannot be disputed. These crack babies often have trouble with basic skills when they are young, and they tend to be fussy and difficult. They also do not socialize well with others, and this can be difficult for them when they enter school. By the age of three, they are generally not much different from other babies, but some studies have shown that their IQ is generally slightly lower and they will have problems socializing with others throughout their lives, even if they have a good intervention early on.

Overall, parents want the best for their children, and it seems that the mothers that are addicted to drugs and alcohol are not out to deliberately hurt their babies. They simply do not know how to stop their addiction, and many of them do not realize the developmental risks that they are taking. By using drugs and/or alcohol during pregnancy, they risk having a child that will be very seriously impaired for the rest of their life, as well as a high prevalence of miscarriage. When babies are born to addicted mothers, their quality of life and health is generally not as high as normal babies.

Biological Facets of Addiction

Addiction can take a toll on the mothers body, and do damage that remains with the mother long-term. This can shorten her life expectancy and cause her many health and wellness problems that could have largely been avoided otherwise. What is important here, however, is not what the drugs can do, but how the mother becomes dependent in the first place based on how the drugs or alcohol make her feel. There are important biological components that are present in addiction, and it is believed that some people are much more prone to addiction than others are.

Whether or not this is actually true appears to need more research but there is evidence, at least where alcoholism is concerned, that addiction and problems with a particular substance does sometimes run in families. Individuals that have alcoholic parents are much more likely themselves to become alcoholics and therefore they must be very careful that they do not allow themselves to fall into this trap. However, when they are young children growing up with an alcoholic mother they often see this type of behavior as normal and therefore do not work as hard to avoid the trap that they may end up in.

This indication that addiction has a strong biological component is very significant based on the fact that a mother that remains predicted to drugs and alcohol throughout her pregnancy gives her child a higher chance of having this same kind of addiction problem later in life. Mothers who become addicted after their child is born do not put as much of this type of biological risk on the child because they were not carrying the child during the time they were using drugs. This does not mean that these mothers are protecting their children or doing what is right for them, but only that the biological issues of addiction are somewhat less for these children whose mothers were clean and sober during pregnancy.

It is also possible that some of these mothers came from homes where their parents were substance abusers as well. Because of this the mother may view much of this behavior as normal and may also have a strong biological component for the addiction that she faces. This is particularly troubling because it makes it harder for these women to address their addiction, get help for it, and ultimately stay clean and sober. This biological role is so strong that it is one of the reasons why alcoholics that truly wish to stay clean and sober must never take another drink. Even one drink could be one drink too many and lead them back down the road toward alcoholism again. Those that have never battled alcoholism or another addiction would likely not understand completely how an individual cannot simply stop at one or two drinks, but the biological craving that many of these individuals have for alcohol is so strong that they are not able to control their alcohol intake once they get started.

Mothers that have this problem and really want to help their children will become more aware of the biological component of alcoholism and other substance dependency. By doing this, they will not only help themselves to recover and be more aware of what it is they are doing to themselves when they drink or use other drugs, but they will also help their children by remaining clean and sober and ensuring that, if they have another pregnancy in the future, they are clean and sober throughout that pregnancy as well so that their baby is not born addicted to drugs or alcohol.

Environmental Facets of Addiction

The biological issues that these mothers face with addiction are not the only problems that can occur. Environmental causes can also been problematic for addiction. Environmental causes generally involve the lifestyle that an individual lives, the family and friends that she associates with, and other factors such as the neighborhood that an individual lives in or is growing up in. Being a single mother, having great degrees of stress, or having other significant issues in ones life that must be dealt with can also be problematic and be considered to be environmental factors of addiction. Simply put, when too many environmental factors build up against a particular individual, she may turn to alcohol or drugs as a way to escape that painful environment and become involved with something that she feels safer in.

Usually, this is a cry for help and the environment that the mother lives in is not actually as painful as she perceives it to be. However, the perception of the environment is extremely important perhaps more so than the reality of the environment. One of the most important and significant issues in the environment is how much stress the mother is under. Once again, this may not be actual stress, but may only be perceived stress. However, whatever causes the stress to be there, or whatever causes the mother to feel as though the stress is there, is what matters to that mother and therefore what has to be dealt with.

Even if the mother feels that she can handle the stress, it is possible that she will struggle with it and she thinks it will end when she turns to drugs or alcohol, even if she has been through recovery, in order to lessen this stress. This is one of the main reasons that another one of the classes will deal with stress, in order to help mothers avoid letting stress build up to the point where they feel as though they must do something about it, because many times when it reaches this point the mothers will turn to drugs or alcohol. One thing in the environment that is often seen as a source of stress is the child, but the child will be discussed in another specific class in addition to the environmental factors class.

When dealing with environmental factors, however, mothers must learn to look at their jobs, their home life, their friends and family, and many other issues that make up their environment. These mothers must then determine what types of problems they are having with each one of these issues so that problem areas can be reduced or eliminated. This does not mean that a mother that is experiencing stress on her job should simply quit and try to live on welfare. This would likely cause more stress. However, a mother that is completely unhappy at her job and finding it as a very large source of environmental stress could look toward securing employment elsewhere where she might be happier.

Even though there are many different environmental issues when it comes to dealing with addiction, most of the environmental concerns and problems generally amount to the idea that there is too much stress in the life of the mother. There is pressure from various sources, and when the mother retains friendships with others that are involved with drugs or alcohol she does not help herself or her child in staying away from addictive behaviors. It may be difficult for a mother to sever ties with individuals that belong to her family or that she is good friends with, but in the best interest of herself and her child she must avoid this common environmental problem.

The Child as a Source of Stress

The overall environment is not the only issue when it comes to stress and problems for mothers. The child that the mother has, or the children if there is more than one, can also be a serious source of stress. The goal of the mother then becomes to understand why she feels so stressful toward the child and how she can look at the actions that the child performs differently so that she will feel less stress toward the child. Modifying the childs behavior in order to produce less stress for the mother would also be very helpful, but this is not always an easy thing to do. Sometimes an individual cannot modify the behavior of someone else and therefore must modify their own behavior in order to deal with what the other individual is doing.

Being able to adjust the behavior of a child is more likely than being able to adjust the behavior of an adult, but if the behavior is something minor that is not actually harming anyone else then sometimes working to change that behavior causes more stress than simply finding a more peaceful way to deal with the behavior as it takes place. Children want attention, and when mothers are physically and emotionally unavailable, these children will often do increasingly more annoying or upsetting things to get this attention. If children cannot get positive attention from their mother, they will look for ways to get negative attention, reasoning that some type of attention is better than being ignored.

This way of looking for attention is one of the things that many mothers find very irritating, and when they are involved with drugs or alcohol and often do not feel well the stress from trying to deal with a child that is demanding of attention can almost be more than they can bear. Even mothers that are clean and sober all of the time sometimes get stressed out over their children and wish they could have a break. For single mothers that may have several children, it is very unlikely that they will ever get a complete break from all of their children for very long. The only way they can feel as though they have gotten this type of break from their children is to resort to alcohol and/or drugs to help them numb some of the pain and stress that they feel. In reality, however, this only makes the problem worse.

These children already need attention, and when they are not receiving this kind of attention from their mother they will work harder at getting her attention. Even if it seems as though the child is withdrawn and sullen, the child still need the mothers attention. Some children as they get older will commit crimes, act up in school, get in fights, and countless other negative actions in order to try to draw the mother out and get her to respond. It is possible that a child will eventually give up on this idea of getting the mothers attention, but only once the child is pretty much grown to the point that he or she can take care of himself or herself. Even at that point, the child might not be good at taking care of himself or herself because it is something that he or she never learned from the mother.

If the mother that is involved in recovery can learn how to lessen the stress that she feels around the child and learn how to look at the child properly so that stress is not the first emotion that comes to mind, it is more likely that the mother will stay clean and sober and that the bond that she should have with the child can be created. This bond will not come overnight and it may take some time for it to strengthen and grow to the point that it should be at. However, it is clear that, as long as the mother sees the child as nothing but a source of stress, there will be no bond between mother and child.

Common Behaviors of Drug-Exposed Babies and Children

Part of the reason that many of these mothers see their children as sources of stress is due to the fact that they do not understand why the child is acting this way. There are many common behaviors that babies and children that were exposed to drugs and alcohol in utero exhibit, and when these are more clearly understood by the mother the stress is lessened by that understanding. However, most of these mothers are not knowledgeable and well read individuals, so they do not understand why the baby or child is acting the way that it is and what can be done about it.

When mothers abuse alcohol and drugs when they are pregnant, fetal alcohol syndrome, crack babies, and other problems can result. These have been discussed under developmental risks, but it is important that mothers see these issues not only as a developmental risk but as an issue that will cause behavioral modifications when compared to babies that do not have these problems. Overall, most babies that are born addicted to a particular substance are fussier and less happy then babies that do not have this issue. This only makes sense, as these babies are dealing with the withdrawal symptoms that adults would also face if they chose to stop to drugs or alcohol. The idea of a tiny, newborn baby going through withdrawal symptoms is not pleasant, but this is often what happens to many of these babies.

Once this has taken place, however, most mothers assume that their child will be just fine but there are other behaviors that also must be understood. Some of these babies that have been born to mothers addicted to crack, alcohol, or other substances are simply not as healthy as babies that were born to mothers that did not use these types of substances while they were pregnant. Because of this, doctor visits, hospitalizations, and general upset over the condition of the child may be something that these mothers will have to deal with, which will lead to greater stress.

As these children grow, common problems generally relate to whether the children develop as quickly as their peers when it comes to cognitive abilities, and whether these children are able to be social with others. Many of these children do not like to play with others and are antisocial to some degree or simply do not know how to relate to others. Many of these same children also have trouble with reading, basic mathematics, and other relatively simple skills that they should be learning at an early age. These are seen as being very common behaviors for many of these babies, but the encouraging news for mothers is that many of these behaviors will lessen and disappear as children get older.

The only area where this does not seem to be the case is with fetal alcohol syndrome. Mothers that use alcohol excessively when they are pregnant generally cause many problems for their babies. Those babies that are born with fetal alcohol syndrome often struggle not only developmentally but behaviorally as well and therefore they have a much more difficult time then crack babies or babies born addicted to other substances when it comes to trying to catch up with their peers. Some of these babies that are born with fetal alcohol syndrome will not be able to catch up with their peers at all and will always be developmentally and behaviorally delayed. This is a tragedy that can easily be avoided but mothers must be educated as to the dangers of alcohol and other drugs during pregnancy.

Absent Parenting

One of the most interesting classes that will be dealt with is that of absent parenting. All of the information that has been provided to the mothers up to this point deals with mothers that live with their children. However, for mothers that have been addicted to drugs or alcohol for some time, it is likely in many cases that these mothers do not live with their children. If the father is available, and if he is clean and sober, the children may live with him. If there are other friends and family members available that are clean and sober, the children may live with them. However, many of these individuals that find themselves in substance abuse and recovery are single mothers that basically do not have anyone else to help them and therefore when they lose custody of their children, at least temporarily, due to drugs and alcohol, these children must be placed in foster care.

This is upsetting, not only for the child but for the mother as well. The child may feel as though he or she has been abandoned, and the mother may feel as though she has failed her child or deserted him or her in some way. Neither one of these things is true, but this does not necessarily stop the parties involved from feeling this way. Getting these children back out of foster care once recovery is complete is often the most important goal of the mother. However, the mother often does not realize that there are things that she can do while the children are in foster care in order to ensure that she keeps in contact with them and that they do not feel lost and forgotten.

Even simple things such as cards, letters, and phone calls, can mean a great deal to the children. These should be encouraged as much as possible provided the mother is clean and sober. While many of these mothers are not allowed to visit the children because these mothers are in residential treatment and cannot leave, being able to be in some type of contact with their children is very important. Not only will the children feel better about the situation and understand that they will get their mother back within a certain period of time, but the mother will feel as though he/she has some hope for the future and that she is being a better mother because she has not abandoned her children.

Being able to talk on the phone, send cards, and send letters is obviously not as good as being able to be in physical contact with the child, but it is certainly better than simply being cut off from the child for a specific period of time. Even a 10-week treatment program is a long time to a young child and children tend to forget people or be shy around people they have not seen in several weeks. This is not to imply that a young child would forget who his mother is after 10 weeks, but the child might be distrustful and shy for a period of time afterwards. If contact between the mother and child can be kept up during the treatment, there is less chance of something like this taking place.

When a mother is absent from the life of a child, it makes it very difficult and painful for the child in many ways. The goal of treatment programs and other issues that deal with recovery from drug and alcohol addiction is to keep families together. Contrary to popular belief, welfare services and other child protective services are not generally trying to take children away from mothers that have problems. Instead, they recognize the bond between mother and child and how significant it can be. Because of this, they try their best to get help for the mother so that the children can remain with her. When this is not possible, they try to reunite mother and child as soon as possible.

However, the extra little bit of contact that a mother can keep with her children through cards, letters, and phone calls can make a great degree of difference in how the mother feels about the children and how she feels about herself as well. Keeping in this type of contact and completing the treatment program appropriately can also indicate to child protective services that the mother is trying to rebuild her life and that she does deserve to have her children with her. This may allow her to receive her children back from foster care more rapidly than she otherwise would have.

For many mothers this is exceedingly important because they simply want their children back. Not all mothers respond that way, but many mothers that have a problem with drugs or alcohol do not see it as any large deal until they realize that their children are being taken from them. Most of these mothers do love their children even if they do not always treat them as though they love them. Being emotionally unavailable for these children can be very painful to them but the mother often does not mean to deliberately emotionally detach herself from her children. It is the drugs and alcohol that are causing this problem. Once recovery begins and sobriety is available to the mother, she realizes much more strongly what it means to be without her children and being able to be in contact over the phone or through the mail with these children can make all the difference to a mother that is trying desperately to recover.

The Repair of the Home Life and the Relationship

Once recovery is complete and individuals that are in residential treatment have been released, these same individuals must look toward repairing the home life and the relationship that they have with their children and with others. This is not always an easy thing to do, but it is something that must be done if the mother and child are ever going to have a strong relationship again. It is not something that can be done overnight and mothers that push for too much progress to quickly might actually push their child away to a certain extent. Because of this, mothers must be careful not to push their children too hard when it comes to getting close either physically or emotionally. They must be open to their children and make their children aware of this, and then they must let the children come to them.

This can be very difficult thing to do because the mother that truly regrets the problems that she has caused for the family due to her drug or alcohol addiction may want to have everything back the way it was before any of this ever happened. It can get back to the way it was before anything ever happened, but it is not something that will happen right away. Mothers that get out of recovery and are working to rebuild their home life and their relationships must take the time to allow these things to come together once again. It took time to cause the damage, and it will take time to undo the damage.

Finding a place to live, finding a job, finding a babysitter, finding transportation, and many other issues have to be dealt with to rebuild a life. If the mother was fortunate she did not lose any or all of these things while she was in treatment. However, the reality is that many of these mothers that end up addicted to drugs and alcohol did not have a decent place to live, a good job, reliable people to watch their children, and a nice car. Because of this, many of the things that the mother did have may have been lost during the 10 weeks she was in treatment. The mother must then work to rebuild what has been lost, and this includes not only material things but relationships with other individuals, including her child, as well.

Rebuilding a relationship with a child can be easy or difficult, depending on several factors. The age of the child is important, the length of time that the mother was addicted to drugs or alcohol is important, and the strength of the bond that the mother and child had before the addiction took place, if any, is also very important. Mothers and their children that have had a strong bond in the past can often get past the addiction issue more easily than those that generally formed no bond before the addiction began.

Those that had a stronger bond originally generally understand one another better and most of these children are also older. Younger children just want their mother back and do not understand why she had to leave them or why they all had to go and stay in a treatment center. Older children understand the need for the treatment center and they understand that what their mother is going through is not something that she did deliberately and not something that she can easily control. In other words, these older children are sometimes more forgiving than the younger ones, but there can also be feelings of anger and betrayal in older children as well. Rebuilding the relationship with children over all and re-creating a stable home life from the pieces that are left can be very difficult, but it will also likely be found to be one of the most rewarding things that the mother has ever done with her life.

Summary of the Program

As can be seen from the classes that were discussed above, there are many different issues that must be addressed when it comes to parenting and substance abuse. Really, parents cannot have both the drugs/alcohol and their children at least not if they are honestly able to look at the way that their lives are and the way that their children feel about the parents, themselves, and others. This concern for the children must be what brings these parents to seek help, and sometimes that concern for their children does not really come until the parents are in treatment and are clean and sober enough to be able to really see their children as people, instead of as property.

It is hoped that these parents do not see their children that way anyway, but sadly many parents do, and it is often the drugs and alcohol talking instead of the true feelings of the parent. Those that have been addicted to one or more substances for a long time may not actually know what their true feelings are anymore, and this is also troubling because these parents, when they get clean and sober, must then try to form bonds with their children and develop feelings for them that they have likely never had before. It can be a long and painful process that sometimes can never be completed. However, the parents have a lot higher chance of completing it if they remain clean and sober after their treatment has ended. Learning all that they can about their children and what they need from them while they are in residential treatment can help them do this.

This also allows for these women not to lose their children, as children are sometimes placed in foster care if there are no reputable relatives that can take care of them while the mother is in treatment. The mother must then work to get her children back when she gets out, and this is not always an easy task. It can be especially difficult if there is any history of abuse or other problems, or if the mother has been in treatment (and therefore lost custody of her children at least temporarily) more than once. This parenting program will help to avoid all of the problems that can come from this kind of issue and therefore will also lower the stress level of the mother when she is released from treatment.

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