Women, Addiction and
Mental Health Issues in the
Drug Courts
Hon. Peggy Fulton Hora
Judge of the Superior Court (Ret.)
LADCP April 11, 2012

“There is nothing more unequal then the
equal treatment of unequal people”
Thomas Jefferson
Female drug use


Approximately 6.6% of women aged 12 and
older reported past month use of an illicit
drug
9,417,840 females
Substance Abuse and Mental Health Services Administration, 2009 National Survey on Drug Use and
Health (NSDUH), September 2010)
Women and Alcohol



2.7 million women abuse alcohol
“moderate” drinking is < 1 drink a day
4 million women need treatment for
substance dependence
1:4 cases of dementia caused by alcohol





Women are at high risk because more
susceptible to alcohol’s “brainwashing”
effects
Women are less able to deal with alcohol’s
toxic effects
Develop more severe complications earlier
Younger drinkers will experience memory
problems sooner
Macrae Fiona, Daily Mail Online, May 11, 2009
Women and drugs in CJ system



Women in the criminal justice system
display an even higher rate of substance
use
59.3% of state and 47.6% of Federal
female prisoners surveyed in 2004
indicated that they had used drugs in the
month prior to their offense
60.2% of state and 42.8% of Federal
female prisoners surveyed in 2004 met
drug dependence or abuse criteria
BJA
Women and Smoking



Women smokers get
sicker at a younger
age than men
COPD reduced lung
function at lower
level of smoking
“Cigarettes More Toxic for Women, Study
Finds,” Join Together Online 5-20-09
“You’ve come a
Long way, Baby”
LA Cost of SA and Addiction


17% of Louisiana state budget = $1,375,626
$320.83 per capita
“Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets,” CASA
(May 2009)
The Burden on SA/Addiction in LA
The Substance Abuse Dollar
Treatment 3 cents
Regulation <1 cent
97 cents of every substance abuse
dollar is spent on the burden of use
Impact on Kids
Females constitute approximately 30% of the
substance addicted population in the United States
and most are of childbearing age
500,000 - 750,000 newborns are
exposed to illicit drugs each year
Among pregnant
women aged 15 to 44
years who participated
in the 2006 National
Survey on Drug Use
and Health, 4.0%
reported having used
illicit drugs within one
month of the survey
Josh Gunn, Ph.D. and Scott Kriger, Ph.D, “The Prevalence of Maternal Drug Use During Pregnancy”
Women/girls use for different reasons


A three-year study on women and young girls
(aged 8–22) revealed that girls and young
women use substances for different reasons
than boys and young men.
Risk factors such as low self-esteem, peer
pressure, and depression make girls and
young women more vulnerable to substance
use as well as addiction
National Center on Addiction and Substance Abuse at Columbia University, The Formative Years:
Pathways to Substance Abuse Among Girls and Young Women Ages 8–22 (PDF) , February
2003
Juvenile prevalence


Of youth in post-adjudication placements,
47% have alcohol and drug disorders
Among high school seniors in 2008, one in 10
(10.4%) reported that in the two weeks prior
to their interview, they had driven a vehicle
after smoking marijuana
Youth with MH/AOD problems


Adolescents with serious behavioral
problems are more than 7 x’s more likely to
report substance dependence
Youth with serious emotional problems are
4 x’s more likely to report AOD dependence
Drug Cases Juvenile Courts




193,700 juvenile drug cases 2004
1991-2004 drug cases doubled
Delinquency caseload for drugs = 7% in
1985 vs. 12% in 2004
Female caseload jumped12%-20% ‘91-04
“Drug Offense Cases in Juvenile Courts, 1985-2004,” OJJDP Fact Sheet, Feb. 2008
Juvenile Justice


Up to 67% of youth involved in the juvenile
justice system have a substance use
problem.
Almost ¾ of youth in correctional facilities
report mental health problems during
screening
Co-Occurring

“[Co-Occurring] is
the expectation, not
an exception.”

Dr. Ken Minkoff
Co-Occurring disorders are
more prevalent in men or
women?
Women
Mental health issues



Co-morbidity complicates
and exacerbates the
problems
Almost 12% of mothers in
the U.S. has serious
mental illness; 3.2% had
SMI + SA
Up to 95% of parents in tx
programs have cooccurring disorders
Post Traumatic Stress Disorder

30-57% women in treatment meet criteria for
PTSD

45-85% of battered women meet criteria

Co-morbidity for PTSD and substance use
disorders is 2-3xs higher for females
Trauma-informed Care



Community corrections, prosecution,
defense and the court must become
“trauma-informed”
Substance abuse and other mental health
issues are closely associated with trauma
SA/MH drives the justice system—both
criminal and child abuse and neglect cases
“Understanding women in court,” SAMHSA, Center on Women, Violence and Trauma
(2006)
Women with Co-Occurring
Primary Drugs of Choice
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
OAS, 2002
Alcohol
Opiates
Cocaine
Marijuana
Stimulant
Other
Cocaine / Alcohol Abusers with
Comorbid Psychiatric Disorder
MEN
Anxiety
Depression
Bipolar
Panic disorder
Social phobia
PTSD
48%
36%
6%
10%
14%
24%
WOMEN
70%
40%
4%
18%
10%
46%
Men vs. Women in Custody


Women inmates have
>symptomology
diagnosed with mental
health problems 3xs
rate of men
Symptoms
Diagnosed
SP
M
SP
F
Jail
M
Jail
F
48%
8%
62%
23%
59%
9%
70%
23%
Women with Co-Occurring More
Likely Than Men to be:







Poor
Uneducated
Poor job skills
Receive public assistance
Report more relatives with AOD problems
Care for more dependents
Depressed, anxious, have eating disorders
and lower self-esteem
“Women with Co-Occurring Mental Illness and Substance Abuse,” AIA Center (May 2005)
Post-Traumatic Stress Disorder (PTSD)



Acute traumatic stress is caused by an
individual's subjective experience of an extreme
traumatic event which can lead to extreme
stress that inhibits a person's ability to cope.
Trauma is defined as a terrifying event that a person
experiences, witnesses or learns about in which
grave physical harm occurred or was threatened.
The traumatic event causes the person to feel
intense fear, terror or a sense of helplessness.
http://www.attcnetwork.org/learn/topics/ptsd/index.asp
Post Traumatic Stress Disorder

30-57% women in treatment meet criteria for
PTSD

45-85% of battered women meet criteria
Co-morbidity for PTSD and substance use
disorders is 2-3xs higher for females

Smokers at higher risk for PTSD

Archives of General Psychiatry (Nov. 05)
“Linda”






41 years old
Alcoholic
Incest survivor but
won’t talk about it
Battered by > one
man
Dx? Tx? Action
plan?
What ?s
New app from VA
Women with Co-Occurring More
Likely Than Men to be:







Poor
Uneducated
Poor job skills
Receive public assistance
Report more relatives with AOD problems
Care for more dependents
Depressed, anxious, have eating disorders
and lower self-esteem
“Women with Co-Occurring Mental Illness and Substance Abuse,” AIA Center (May 2005)
Allowing women to have
their children with them while
in treatment increases
treatment success
TRUE
The number one barrier to
treatment for women is:
Lack of child care and fear of losing
their children
The number two barrier to
treatment for women is:
Being battered
FALSE
The number one risk factor for alcoholism is
childhood sexual abuse.
Childhood Sexual Abuse




It is the second most
prevalent risk factor
Applies to both boys and
girls
70-90% of women in tx
were sexually abused
before age 16
7-16% men in jail report
physical or sexual abuse
before 18
Aristotle said,
“…women who drink wine
excessively give birth to
children who drink
excessively of wine.” 350
B.C.
Becoming trauma-informed



Community corrections, prosecution,
defense and the court must become
“trauma-informed”
Substance abuse and other mental health
issues are closely associated with trauma
SA/MH drives the justice system—both
criminal and child abuse and neglect cases
Understanding women in court
SAMHSA, Center on Women, Violence and Trauma (2006)




48-90% women with SA/MH issues have
histories of interpersonal abuse
First occurrence when child or adolescent
Intergenerational issues – survivors often
lost custody of their own children due to
abuse and neglect
In dependency cases, AOD is present >50%
of the time
Traumatic stress during childhood




Can affect physical/mental health
Relationships
School performance
Risk taking in childhood and as an adult
Summary of Physical /Sexual Assault Across the
Lifespan (U.S.A.)
National
Figures (All
U.S. Women)
Women Living
In Poverty
Incarcerated
Women
40%
63%
70%
Sexual Molestation in
Childhood Before Age 16
(Any Perpetrator)
20-27%
42%
59%
Any Physical Violence or
Sexual Molestation in
Childhood
Not Available
72%
82%
22%
61%
75%
Not Available
83%
94%
Severe Physical Violence by
Childhood Caretakers Before
Age 18
Severe Physical Violence by
Adult Intimate Partners
Physical Violence or Sexual
Assault by Intimates over
Lifespan
25 years to grow a mature one



18-25 “apprentice
adults”
Exposure to traumatic
stress can affect
developmental
processes
Increases risk of SA,
criminal activity,
homelessness and
revictimization
Another recent survey showed:



1:5 girls have been
sexually or physically
abused
The abuse occurred at
home (53%)
It happened more than
once (65%)




The abuser was a
family member (57%)
Or a family friend (13%)
29% told no one
Have increased
likelihood of SA or
eating disorders
Tanya’s story


“When I was a child, my father used to rape
me. It started when I was nine…. After I ran
away, I wanted somebody to want me. I ran
into this guy, he was older, and I wanted him
to want me. He gave me cocaine. I was
13.”
Quotation from Tanya, interview on 7/9/98, Hirsch, Amy E., “Some Days are Harder than
Hard,” Welfare Reform and Women with Drug Convictions in Pennsylvania, Center for
Law and Social Policy, (Dec. 1999)
Age of Onset of Drinking
Is a Risk Factor


Every year before 21
increases likelihood of
problem drinking by
12%
Early drinkers need
more alcohol to get high
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Age
13:
42%
Age
16:
22% Age
21:
10%
Adolescent Substance Abuse


The younger an individual is at the onset of
substance use, the greater the likelihood that
a substance use disorder will develop and
continue into adulthood.
More than 90% of current substance abusers
started using before the ago of 18; half
started before age 15
Age of onset of drinking



If first drink at 13, 47% risk of becoming
alcoholic;
if from alcoholic birth parents, 60%;
if from non-alcoholic birth parents, 30%
Abstinence until 21

A child who reaches
age 21 without
smoking, using illegal
drugs or abusing
alcohol is almost
certain never to do
so.
"A drug-free future begins here," CASA 2001
Annual Report
Risk/Protective Factors


Risk factors include availability of drugs,
family history of substance abuse, learning
disabilities and other academic difficulties
and peers who use.
Protective factors include a supportive,
involved family which practices abstinence.
One supportive adult can make a difference.
Kids with addicted parents



12% children live with
at least one parent w/
substance abuse
7.3 million kids with
alcohol abusing folks
2.1 million kids with
drug abusing folks
“Many U.S. Kids Have Addicted Parents, SAMNSA Says,” Join Together Online 5-5-09
CHILDREN OF ALCOHOLICS



Alcoholism affects the entire family
Many people are exposed to alcoholism in
their families
There is strong, scientific evidence that
alcoholism tends to run in families. Children
of alcoholics are more at risk for alcoholism
and other drug abuse than children on nonalcoholics.
COA’s Cont.



Alcoholism usually has strong negative
effects on marital relationships
Alcohol is associated with a substantial
proportion of human, violence and
perpetrators are often under the influence of
alcohol
There is a strong relationship between
parental alcoholism and child abuse
COA’s Cont.



COAs exhibit depression and anxiety more
than non-COAs
COAs score lower on tests measuring verbal
ability
COAs often have difficulties in school
COAs, cont.



COAs have difficulty with abstraction and
conceptual reasoning
COAs can benefit from protective factors
such as developing a close bond with a
caregiver
Consistency of family activities can be a
protective factor


2.5 million children in
the U.S. are being
raised by grandparents
or other relatives
Family care has
increased by more
than 86%
“Mindy”
•17 years old
•Thinks baby will solve all her
problems
•Smokes cigarettes and marijuana
•Drinks a couple 40s per week
•She’s is worried about harming
the baby
•How can you help her? What do
you say? Is it too late? What can
she expect?
The most important factor in assuring a
healthy birth outcome for an addicted,
pregnant woman is:
Prenatal care
Rank the following substances in terms
of the number of fetuses effected:
Crack cocaine, Tobacco, Alcohol
1.Tobacco
2. Alcohol
3. Crack cocaine
Science…

…must outweigh stigma, prejudice, and
misunderstanding.

Addiction is not so much a failure of will as a
failure of brain chemistry.
Cocaine-Exposed Children

Trained research
assistants, unaware of
a child’s history,
cannot tell the
difference between a
4-year-old who was
exposed to cocaine
before birth and one
who was not.
Children, cont.

Most maladaptive behavior and
developmental delay in children from
urban and impoverished areas is not
uniquely due to prenatal cocaine exposure.
Conversely, prenatal exposure does not
necessarily lead to developmental delay or
behavioral problems.
Children, cont.

Stigma itself is a social and developmental
risk to children who were cocaine-exposed
prenatally, regardless of the
pharmacological effects of the drug or the
reasons for assuming cocaine exposure.
Children, cont.

Labeling children as cocaine-exposed may
lead to the imposition of negative
expectations, which in turn undermines
the children’s cognitive and behavioral
development.
How to Correct for Exposure?


The quality of the care giving environment was the
strongest independent predictor of outcomes
Cocaine-exposed children placed in homes with a
stimulating environment and with caregivers with
good vocabulary scores attained full-scale and
performance IQ scores
Singer, et al., “Cognitive Outcomes of Preschool Children with Prenatal
Cocaine Exposure,” 291:20 Journal of the American Medical Association
(JAMA) (May 26, 2004)
FALSE
Babies born of mothers who use drugs during
pregnancy are born “addicted.”
Addiction required a fully developed nervous system.
Not all babies are susceptible. There is no hard
evidence that such babies seek drugs or lose control
over drugs.
Brick, J. and Erickson C.K., Drugs, The Brain, and Behavior: The Pharmacology of
Abuse and Dependence. The Hayworth Press, Binghamton, N.Y, (1999)
CPS Issues for Using Parents


70% of child
abuse/neglect cases
are based on AOD
abuse
Children in alcoholabusing families are
almost 4 times more
likely to be victims of
maltreatment
Fetal Alcohol Spectrum Disorder
Alcohol use by pregnant/recent
mothers: 2002-2007




11.6% pregnant women drink
16% teen pregnant girls drink consuming an
average of 4 drinks over 6 days during the
past month
42.1% recent mothers drink
54% all women drink
“Alcohol Use among Pregnant Women and Recent Mothers: 2002-2007,” The NSDUH Report (Sept.
11, 2008)
FAS/FASD







4 million pregnancies in US annually
40% women drink while pregnant
3-5% drink “heavily” (5 drinks/day)
FAS birth rate from heavy drinkers = 6%
FASD rate 0.97% - 9.1%/ 1,000
80% of FAS exposed to other drugs
Floyd, R.L. & Dishu, J.S. (2004) “Monitoring prenatal alcohol exposure,” Am. J. Medical Genetics
127C, 3-9; Abel, E.L. (1998) Fetal Alcohol Abuse Syndrome Plenum Press, NY NY
Mothers of FAS Children




80 % had major mental illness
100% sexually, physically or emotionally
abused
80% lived with men who did not want them to
stop drinking
60% with phobias, most common
agoraphobia, so they are unable to seek help
outside their home
Role of Genetics

Genetics may influence whether or not a child
exposed to alcohol in-utero is born with birth
defects
Mouse models

Alcoholism: Clinical and Experimental Research, April 21, 2009

Alcohol


“We know that substance use by pregnant
women is a leading cause of mental, physical
and psychological problems in infants and
children.”
Charles G. Currie, former SAMHSA Administrator
Substance Abuse is a Family Disease

Mothers’
substance
use/abuse may
have lifelong
effects on
children
But Treatment Works




CSAT study showed 2:3 women not using
AOD after tx
86% of mothers had their children
fewer than 10% were involved with criminal
justice
Women are more likely to initiate tx and
remain drug free after tx
Green, Carla A., Ph.D., M.P.H., “Gender and Use of Substance Abuse Treatment Services,” Alcohol Research
& Health 29:1 2006
Girls in the Juvenile Justice System


Barriers to Tx for Girls in the Juvenile
Justice System

The Violent Crime Index arrest rate for girls
rose 103% between 1981-1997 vs. 27% for
boys.

The biggest increase was for drug abuse
and curfew violations
Intergenerational incarceration


Family stressors include poverty, death, and
an intergenerational pattern of
arrest/incarceration.
54% of girls have mothers who have been
arrested/incarcerated
Lack of stability


95% of girls in the Juvenile Justice system
lack a stable home environment
91% have been suspended, expelled or
repeated one or more grades.
Education


School is described as a “battleground” with
sexual harassment, racism, interpersonal
rivalries with peers and inattention from
adults.
Dropping out is seen as a necessary means
of escape.
Mental health issues



88% experience serious health problems;
53% need psychological services.
21% have been hospitalized in a psychiatric
facility
Mental health issues



88% experience serious health problems;
53% need psychological services.
21% have been hospitalized in a psychiatric
facility
Victimization
•
Girls’ and women’s pathways to offending
is victimization.

92% of juvenile female offenders report some
form of emotional, physical or sexual abuse.
Violence

Girls age 13-14 are most likely to be beaten,
stabbed, shot or raped.

25% report being shot or stabbed one or more times

11% of girls witnessed or experienced the death of
one or both parents or a sibling
Pregnancy

29% of girls had been pregnant one or more
times;

16% had been pregnant while in custody

Gangs/Young Women of Color

47% report gang affiliation

2/3 of the girls are of color, primarily African
American and Latina
Girls underserved

“Girls in and on the edge of the juvenile
justice system represent one of the leastserved juvenile justice populations. “
“Investing in Girls: A 21st Century Strategy,” VI JUVENILE JUSTICE JOURNAL
3 NCJ 178254 (Oct. 1999)
Barriers to Tx for women




What to do with the
children?
Who will pay for tx?
Shame
Denial
BARRIERS TO TREATMENT FOR
WOMEN WITH CHILDREN

STIGMA,
particularly for
drug-using
mothers
Former First Lady Betty Ford
“As a recovering woman, I
have personally
suffered the scorn of
others who are
confused, bitter and
misled about addiction.
…[H]ow could a nice
person like me be an
alcoholic?”
Lack of child care


An average of 8% treatment facilities offer
child care. When women can take their
children to treatment, there is improved
retention and treatment success
Loss of income and inability to pay for
treatment
Fear of losing custody

More than half (58%) of AOD directors and
CPS directors said in 1995 a positive drug
test is grounds for reporting a pregnant
woman to a state agency compared to 12%
in 1992
Fear of prosecution

Fewer than ½ (45%) of state AOD and CPS
directors reported criminal prosecution of
drug using women in 1992 in their state
compared to 71% by 1995
Suppression of violence

Suppression of violence including rape,
incest and domestic violence can trigger
relapse and is a critical issue that must be
addressed in treatment.

Recovery can be too painful for some
women.
Programs offering women-specific
programming




43.2% Methadone programs
41.7% Residential
35.4% Outpatient
46.9% Residential/Outpatient
Gender Specific Services:
“…those designed to meet the unique needs of
female offenders, that value the female
perspective, that celebrate and honor the
female experience, that respect and take into
account female development and that
empower young women to reach their full
potential.”
Girls, Inc. 1996
Women-only Tx





During tx, no significant differences
After 6 months, continuous reductions in use
for those in women-only tx
Especially for alcohol tx
Women-focused and women-only have longterm positive outcomes
Greenfield, et al., “The Women’s Recovery Group study: A Stage 1 trial of women-focused therapy for substance
use disorders versus mixed-gender group drug counseling,” Drug and Alcohol Dependence 90:39-47, 2007
Resources:
Substance Abuse Treatment for Women Offenders:
Guide to Promising Practices (TAP 23) CSAT
http://ncadistore.samhsa.gov/catalog/productDetails.as
px?ProductID=15498
 A Woman’s Way Through the Twelve Steps by
Stephanie Covington
 Women for Sobriety, Inc.
http://www.womenforsobriety.org A non-profit
organization dedicated to helping women overcome
alcoholism and other addictions

Resources
Resources
Resources

Mental Health webliography
Co-Occurring webliography
Alcohol and Other Drug webliography
Women Specific Websites
Listserv

peggyhora@sbcglobal.net



