The Romano Family.
Carl Stuart
Stuart Medical Series
Abstract
Substance abuse is considered a family disease. Substance
abuse within a family predisposes every family member to depression, mood
swings, stress, guilt, anxiety, temper tantrum and social isolation. A child living
in such a family would show the following symptoms: guilt, poor interpersonal
relationships, embarrassment, anxiety, anger, confusion, depression and
inability to form stable or close relationships. In school, the child would
exhibit delinquent behavior, truancy, aggressiveness and various risk-taking behaviors.
Substance abuse causes a dysfunctional family, and treatment of the entire
family is necessary to reverse the effects of drug abuse. Thus, addiction
within the family requires a management plan that covers the entire family.
Introduction.
Substance abuse is considered
a family disease because a chemically dependent parent would create a
dysfunctional family system. The dysfunctional family system aggravates the
addiction of the parent or it causes the parent to abandon his parental duties.
When an addict joins a family system, the family would undergo the following
four phases: learning phase, seeking phase, harmful phase and finally the
escape phase. Parents who engage in substance abuse expose their children to
the following adverse emotional conditions: ambivalence, insecurity, anxiety,
sexual ambiguity, guilt, confusion, fear, mistrust and shame. The consequences
of parental substance abuse can be categorized as follows: behavioral (family
members would exhibit socially unacceptable behavioral patterns), economical
(financial difficulties due to the addiction and treatment costs), medical
(members of a dysfunctional family are exposed to vast array of ailments that
require medical attention), social (the family would suffer from social
isolation), educational(poor school performance among the children) and
psychiatric (substance abuse predisposes the addict to highly morbid
psychiatric conditions). Thus, an
effective management (treatment) plan for treating the substance abuse (within
the family) must involve the entire family (Barth, 2009). Thus, addiction
within the family requires a management plan that covers the entire family
A substance abuser within the
family makes each and every member of the family prone to rage, depression,
mood swings, incessant arguments, defensiveness, stress, guilt, anxiety, low
quality of life, temper tantrum, preoccupations and social isolation. Research
has shown that such afflicted families avoid tackling the real problem. The
families do this in the following ways: they deny the existence (or minimize
the extent) of substance abuse within the family, they avoid discussions about substance
abuse, blame other people for their situations, they provide justification for
the wrongdoings of their children and they avoid any form of assistance. The
child living in such a family is bound to experience the problems stated
hereafter. To begin with, the child feels embarrassed. Embarrassment is due to
the fact that the child has realized the dysfunctional nature of his family,
and as such he would avoid inviting anyone home or even seeking for assistance.
Secondly, guilt in the child is attributed the fact that the child may hold
himself responsible for causing the parental substance abuse and the subsequent
family dysfunction. Thirdly, the child may fall into depression after he
realizes his helplessness in reversing the situation, and this predisposes the
child to lonesomeness. Also, there would be confusion in the child since he
cannot comprehend and adapt to the change in behavior in his parents. In
addition, the child would suffer from anxiety which can be attributed to the
unpredictability of the erratic nature of the behaviors of his parents. Furthermore,
anger in the child would be directed towards the parent who is engaging in
substance abuse and also the normal parent (the one who does not abuse drugs)
for not supporting and protecting him from the erratic substance abuser. Finally, such a child would be unable to form
close relationships with anyone due to the fact that he has suffered from
frequent disappointments from his parents and (sometimes) siblings (Barth,
2009).
The problems faced by a child
living in the dysfunctional family would cause the child to manifest a unique
pattern of behaviorisms, mannerisms and social interactions as is explained
below. In school, the child would exhibit truancy, malingering behavior, aggressiveness
to classmates, poor academic performance, temper tantrums, reclusiveness and
disrespect towards his teachers and seniors. The aggressive behavior and the
tantrums of such a child would also cause him to be involved in numerous fights,
and he would thus be unable to form stable friendships. The child may also
engage in substance abuse, and thus engage in delinquent behavior, and other
risky behaviors, in order to sustain his addiction. Also, the child would
exhibit symptoms of hypochondria and clinical depression (Barth, 2009). The
case study below exemplifies a situation of substance abuse within a family.
Case study:
The Romano Family.
It was only
two weeks into the new school year and the teachers and administration at the
high school and grade school could not figure out what the problem was with the
six Romano children (ages 16, 14, 13, 11, 7, and 6.). All of their teachers
described the children as “unusual” this year. The children seemed angry, kept
to themselves, did not have many friends and never invited anyone over to their
house. All of the children were in some kind of trouble most of the time. Both
parents worked fulltime and were hard to reach by the school, however, when
speaking with the parents, the teachers and school administration found them
“normal”. Recently the 14 year-old called her teacher a derogatory name and ran
out of the classroom. When the teachers spoke with the parents (Mr. and Mrs.
Romano), the parents maintained that absolutely nothing was wrong at home and
nothing had changed. They suggested that this kind of behavior seemed to them
to be typical of 14 year-olds. Two weeks later, each one of the children began
to act out - some of the children got into fights with other students, some of
the children talked back to their teacher and ran out of the classroom.
Discussion
and Diagnosis.
The Romano family is an exemplar of
a dysfunctional family. The parents feign not to notice that the behavior of
their children has changed as compared to the previous year. It can thus be
inferred that the parents are denying the existence of a behavior change in
their children. Also, the parents’ pretence of normal behavior seems to have
convinced the teachers and the school administration that the family is
functional as normal. This pretence enabled the parents to project an image of
a normal family, and they were thus able to avoid any discussion about their
family life. The pretence and denial of children’s behavior change implies that
the parents understood the problem at home, but they did not want to seek any
form of assistance from the appropriate experts.
All the children exhibit the
following symptoms: anger, reclusiveness, guilt and an inability to form stable
friendships. Moreover, all of them seem to be break school rules and
regulations frequently, and thus they are constantly in trouble with the school
authorities. The 14-year old child had a temper tantrum, and she thus insulted
her teacher and thereafter got out of the class. A fortnight later, all the
children exhibited aggressive behaviors and they were involved in fights with
other children. This shows that within those two weeks, the situation at home
got worse, and hence the children could no longer hide their feelings and
pent-up anger. This behavior patterns are manifested by children who live with
parents who engage in substance abuse.
The behaviors of the children
indicate a dysfunctional family whereby none of the family members has sought
any assistance, and as such the situation seems to deteriorate as is
exemplified by the worsening anti-social behaviors of the children. Based on
the behaviors of the children and the parents, both a working diagnosis and a
definitive diagnosis can be made.
For this
case, the working diagnosis is substance abuse, and the definitive diagnosis is
parental substance abuse.
Treatment.
The treatment
plan for the Romano family will involve a combination of pharmacotherapy, and
non-pharmacotherapy evidence-based interventions.
Pharmacotherapy
involves use of the medications stated hereafter. Addiction to opioids or opioid-like
drugs can be treated by the synthetic opioid, methadone, or opioid anatagonits
such as naloxone and naltrexone. Buprenorphine is a long-acting synthetic
opioid agonist that can be used to treat opioid addiction, but it must be used
concurrently with nalorphine to avoid withdrawal symptoms upon termination of
its use. Alcohol addiction can be managed by the following drugs: Naltrexone,
acamprosate, oxazepam, thiamine, disulfiram, fomepizole and lorazepam. Verenicline
is used to cause cessation of smoking. Rimonabant is used to treat addiction to
marijuana and other cannabinoid-based stimulants (Soyka & Rosner, 2008). The
children would require the following drugs: anxiolytics (such as fluoxetine,
diazepam, clonazepam, nardil, hydroxyzine, pregabalin and buspirone),
antidepressants (such as selegiline, trazodone, paroxetine, imipranie and
clomipramine) and mood-stabilizers (such as haloperidol, lithium, lamotrigine, topiramate,
carbamazepine, gabapentin, sodium valproate, riluzole and risperidone). Moreover,
research has shown that the consumption of omega-3-fatty acids do promote a
state of healthy mood (Rao et al, 2008).
Minnesota model evidence-based models of education and
treatment are the main non-pharmacotherapy
interventions that can be used. These interventions are categorized as follows:
motivational interviewing, cognitive behavioral therapy (CBT), community reinforcement
approach, contingency management and family systems therapy. Prior to the
commencement of therapy, the psychologist must be non-judgmental and must apply
positive reinforcement in order to achieve a good prognosis (O'Donohue & Ferguson, 2006).
Motivational
interviewing would be applied to the parents. Motivational interviewing requires
the psychologist to elicit self-motivational statements from the patients in
order to foster behavioral change. During motivational interviewing the psychologist
must do the following: express sympathy via reflective listening, develop
discrepancy that links the values and goals of the parents and their current pattern
of behaviors, avoid direct confrontation because it can lead to an argument,
adapt to the resistance of the parents, and, he must promote and support the
parents’ optimism and self-efficacy (Armein et al, 2003).
Community
reinforcement approach involves training and incorporating the parents into a
program such as a non-drinking club whereby former alcoholics discuss how they
overcame their addiction. This approach is augmented if the parents use anti-addiction
drugs (such as Naltreoxone) to manage their addictions. The children would be
assisted to join a club which is made up of children who have come from
formerly dysfunctional families that had undergone complete rehabilitation.
Here, the children would be able to relate their experiences with that of other
children and in the process, they would overcome their fears, anxieties,
confusion and apathy; and they would progress smoothly towards the appropriate
behavioral changes. It can be inferred that the community reinforcement
approach offers the best contingency management against relapse and the
ailments associated with the withdrawal of the drugs (John & Gray, 2008).
Contingency
management involves programs that foster adherence to an appropriate behavioral
therapy strategy, while concurrently averting relapse and withdrawal symptoms.
It usually uses positive reinforcement to promote adherence to the behavioral
therapy (O'Donohue & Ferguson, 2006). Thus, it can be applied to the entire Romano family.
CBT can be
applied to the children to enable them to cope with their dysfunctional
emotions (mood disorders, depression and anger) and their maladaptive (or
anti-social) behaviors. It involves directive procedures whereby the
psychologists guides the each and every child through a series of psychotherapy
sessions that are aimed at alleviate the children’s symptoms and also eliminate
their sense of vulnerability. CBT is used alongside pharmacotherapy in order to
ensure effective treatment (Driessen & Hollon,
2010).
Family
systems therapy aims to foster and maintain an appropriate level of
interactions among family members. These interactions would ultimately promote
cordial, harmonious and mutually beneficial parent-child, parent-parent and
child-child relationships. The therapy involves directive procedures whereby
the psychologists guides each member of the family through a series of
psychotherapy sessions that are aimed at improving his or her interrelationships
skills and eliminating suspicions among family members. The techniques that the
psychologist uses include: genogram, attachment-focused family therapy,
systemic coaching, psycho-education, relationship education and psychotherapy.
The therapy is used concurrently with the appropriate medications. Moreover,
this therapy is usually made more effective by integrating it with the
appropriate form of contingency management (Sprenkle
& Bischof, 1994).
Effects of substance abuse.
Substance
abuse is the misuse (or excessive consumption) of any substance/drug (synthetic
or natural) for their psychoactive or psycho-depressive non-therapeutic
effects. The most commonly abused drugs are: alcohol, barbiturates, opioids,
cocaine, amphetamines, benzodiazepines and methaqualone. Substance abuse is
associated with several adverse effects which are described below
(McCabe, Boyd & Teter, 2009).
The effects
of alcohol abuse are: intoxication, delirium tremens, CNS (central nervous
system) depression, amnesia, Wernicke-Korsakoff syndrome, vomiting, nausea, talkativeness,
respiratory depression, euphoria, anxiety, impaired sensorimotor functions, delusions,
suicidal tendencies, hallucinations, poor motor coordination, ataxia, unstable
gait, alcoholic dementia, ketoacidosis, alcoholic liver cirrhosis, sexual
dysfunction, anovulation, polyneuropathy, stupefaction, impaired cognition, pancreatitis,
peptic ulcers, sedation, muscle relaxation and coma (or death)
(McCabe, Boyd & Teter, 2009).
Opioid
dependence is associated with several effects. The main effects are listed
below: euphoria, nausea, vomiting, urticaria, constipation, miosis, drowsiness
and dryness of the mouth.
The minor effects (that usually manifest
themselves after an overdose) are: hallucinations, opoid-induced hyperalgesia, lowered
immunity, respiratory depression, delirium, facial flushing, low testosterone
levels, myalgia, osteoporosis, confusion, biliary(and sometimes ureteric)
spasms, irregular heartbeats, persistent myoclonus, transient impotence, orthostatic hypotension,
hypothermia, migraine and urinary retention (McCabe,
Boyd & Teter, 2009).
Methaqualone
abuse causes the following effects: euphoria, slurring of speech, aphrodisia, transient
headaches, bradycardia, hypoventilation, drowsiness, paraesthesia, respiratory
depression and photophobia. Mathaquolone overdose causes hyperreflexia,
hyperemesis, renal failure, delirium, hypertonia, convulsions, coma and
cardiopulmonary arrest (and ultimately death) (McCabe,
Boyd & Teter, 2009).
Abuse of benzodiazepines is
associated with the following effects: euphoria, blurring of vision, poor
appetite, depersonalization (especially borderline personality disorder),
hypotonia, sedation, muscle relaxation, drowsiness, irritability, poor
concentration, disinhibition, impaired motor coordination, low libido,
hypotension, nightmares, impulsivity, aggressiveness, respiratory depression, impaired
visiomotor coordination, nausea, anterograde amnesia and overall cognitive impairment(McCabe, Boyd & Teter, 2009).
Barbiturate abuse is
associated with the following effects: sedation, lethargy, Steven-Johnson
syndrome, poor motor coordination, cognitive impairment, speech difficulty,
hypoventilation, depression, respiratory depression and coma (which can cause
death) (McCabe, Boyd & Teter, 2009).
Cocaine dependence is
associated with the following effects: euphoria, anxiety, overconfidence, tremors,
alertness, improved exercise endurance, paranoia, high libido, paranoia, psychosis,
CVA (Cardiovascular accidents), akathisia, depression, irritability, agitation,
myalgia, convulsions, hyperthermia, paranoid delusions, transient hypertension,
tachycardia, psychomotor retardation, pruritis, lethargy, hoarseness of voice,
dyspnoea and coma(which can lead to death).
Addiction to amphetamines is associated with the following
effects: euphoria, hyperactivity,
vasoconstriction, high libido, facial flushing, anxiety, restlessness, self-confidence,
bruxism, tachypnea, hypertension, diaphoresis, arrhythmias, constipation,
numbness, insomnia, mental fatigue, high self-esteem, increased appetite, palpitations,
tremors, aphasia, pallor, seizure, blood shot eyes, grandiosity, irritability,
paranoia, psychosomatic disorders, amphetamine psychosis, weight loss, obsessive
pattern of behaviors, aggression and psychomotor agitation(McCabe,
Boyd & Teter, 2009).
Impact of substance abuse among diverse populations.
Substance
abuse is detrimental to the society due to its adverse effects such as truancy,
crime, accidents and morbidities. Among pregnant mothers, substance abuse is
associated with an increased incidence of miscarriages, stillbirths and birth
defects such as fetal alcohol syndrome, phocomelia and tetralogy of Fallot.
Among the working populations, substance abuse is associated
with increased risk of injuries due to falls, slips, road traffic accidents,
fires, assaults, machine accidents and asphyxiation. It also has economic costs
due to treatment of injuries, medical treatment of diseases caused by substance
abuse, fines, litigation fees and the subsequent drainage of financial
resources in order to sustain the addiction (Bouchery
et al, 2011).
In the
healthy segment of the population, substance abuse predisposes them to acute
conditions such as acute pancreatitis, liver steatosis, acute renal failure,
dehydration, anemia and coma. Moreover, substance abuse has been implicated in
the causation of chronic conditions such as liver cirrhosis, anovuloation,
neoplasias, diabetes, gout, arthritis and osteoporosis.
Among the adult population, the social
costs of drug abuse are due to the effects of the substance on the central
nervous system, with the resultant effect of impaired cognition, mental
fatigue, depersonalization, impaired judgment and poor psychomotor
coordination. The substance abusers are hence likely to commit criminal
offences such as rape, domestic violence, assault, child abuse, burglary and
even murder. Impaired cognition and faulty judgment leads to inappropriate
behavior, public disorder, participation in risky activities, marital divorce,
child neglect, drunk driving and its associated frequent civil penalties or
even incarceration. Moreover, the addict is isolated by the society, and this
leads to emotional disorders such as depression and even suicide. Also, high
rates of alcohol consumptions among various communities have led to stereotypes
such as the drunken Irish. Moreover, most drug addicts lose their jobs hence
plunging their families into financial difficulties (Bouchery
et al, 2011).
Conclusion.
Substance abuse is considered
a family disease because a chemically dependent parent would create a
dysfunctional family system. In the case of the Romano family, the
working diagnosis is substance abuse, and the definitive diagnosis is parental
substance abuse. The treatment plan for the Romano family will involve a
combination of pharmacotherapy, and non-pharmacotherapy evidence-based
interventions. These interventions are categorized as follows: motivational
interviewing, cognitive behavioral therapy (CBT), community reinforcement
approach, contingency management and family systems therapy. It is thus
apparent that effective management plan for treating substance abuse within
a family must involve the entire family. Hence it can be concluded that addiction
within the family requires a management plan that covers the entire family.
References.
Barth, R. (2009). Preventing
Child Abuse and Neglect with Parent Training: Evidence and
Opportunities. The Future of Children, 19(2), 95-118.
O'Donohue,
W& Ferguson, K. (2006). Evidence-Based Practice in Psychology
and Behavior analysis. The Behavior Analyst Today, 7(3): 335–350. Retrieved from http://www.baojournal.com/BAT%20Journal/VOL-7/BAT-7-3.PDF.
Soyka,
M & Rösner, S. (2008). Opioid antagonists for pharmacological treatment of
alcohol
dependence – a critical review. Current
Drug Abuse Review, 1 (3): 280–91.
Retrieved from http://www.eurekaselect.com/92840/article.
Rao,
J; Lee, H; Rapoport, S; Bazinet, R. (2008). Mode of action of mood stabilizers:
is the
arachidonic acid cascade a common target? Molecular
Psychiatry, 13 (6): 585–96.
Retrieved from http://www.nature.com/mp/index.html.
Amrhein,
P; Miller, W; Yahne, C; Palmer, M; Fulcher, L. (2003). Client commitment
language
during motivational interviewing
predicts drug use outcomes. Journal of Consulting and
clinical Psychology,
71
(5): 862–78. Retrieved from
Joseph,
J. & Gray, M. (2008). Exposure Therapy for Posttraumatic Stress Disorder. Journal
of
Behavior Analysis of Offender and
Victim: Treatment and Prevention,
1(4),
69–80.
Retrieved from http://www.baojournal.com/BAT%20Journal/VOL-1/BAT-1-4.pdf.
Driessen,
E & Hollon, D. (2010). Cognitive behavioral therapy for mood disorders: efficacy, moderators and
mediators. Psychiatric Clinics of North America, 33 (3): 537–55.
Retrieved from http://linkinghub.elsevier.com/retrieve/pii/S0193953X1000047X.
Sprenkle,
D & Bischof, G. (1994). Contemporary family therapy in the United
States. Journal of
Family Therapy, 16
(1): 5–23. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1467-6427.1994.00773.x/abstract;jsessionid=C1FF917A17AA795DDB33A7DF1FDD5CC2.d04t02?systemMessage=Wiley+Online+Library+will+be+disrupted+on+15+December+from+10%3A00-12%3A00+GMT+%2805%3A00-07%3A00+EST%29+for+essential+maintenance.
McCabe, S; Boyd, C &
Teter, C. (2009). Subtypes of nonmedical prescription drug
misuse. Drug
and Alcohol Dependence, 102
(1-3): 63-70. Retrieved from
Bouchery, E; Harwood, H;
Sacks, J; Simon, C; Brewer, D. (2011). Economic Costs of Excessive
Alcohol Consumption in the U.S., 2006. American
Journal of Preventive Medicine, 41
(5): 516–524. Retrieved from http://www.ajpmonline.org/article/S0749-
3797%2811%2900538-1/fulltext.
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