Fetal Alcohol Spectrum Disorders in Mental Health
and Criminal Justice
Instructor: Dr. Dawn-Elise Snipes
Executive Director AllCEUs.com, Counseling Continuing Education
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
CEUs are available for this podcast at https://allceus.com/member/cart/index/product/id/127/c/
Objectives
~ Where to begin…
~ Explore the scope of the problem
~ Identify the impact of the impairments across life domains
~ Discuss specific issues for adolescents
~ Identify special issues for suicide intervention
~ Explore techniques to modify the treatment environment to accommodate the needs of a person with an FASD
Stats
~ National Institute on Alcohol Abuse and Alcoholism, the prevalence of FAS in the general population ranges from 2% to 5% for the entire continuum of FASD.
~ 94% of individuals with an FASD also have a mental illness
~ 73-80% of children with full-blown FAS are in foster or adoptive placement
~ 61% of adolescents with an FASD experienced significant school disruptions
Stats cont…
~ The prevalence of FASD in the child welfare system is approximately 17 to 19 times higher than that in the general population in North America (meta-analysis published online September 9 in Pediatrics).
~ 12.8 is the average age children with an FASD begin having trouble with the law. (https://www.mofas.org/2014/05/fasd-and-the-criminal-justice-system/)
~ 60% of people with an FASD have a history of trouble with the law
What is FASD
~ FASD is not a diagnostic term, but is an umbrella term encompassing four categorical diagnostic entities:
~ Fetal alcohol syndrome (FAS)
~ Partial FAS
~ Alcohol-related neurodevelopmental disorder
~ Alcohol-related birth defects
Impact of Functional Impairment
~ Problems in multiple domains interferes with treatment success, including inability to:
~ Remember program rules or follow multiple instructions.
~ Remember and keep appointments, or to get lost on the way there.
~ Independently make appropriate decisions about treatment needs/goals.
~ Appropriately interpret social cues
~ Observe appropriate boundaries, either with staff or other clients.
~ Attend to (and not disrupt) group activities.
~ Process information readily or accurately.
~ ‘Act one's age.’
~ When indicators occur in any these domains (and particularly when they occur across multiple domains), it is worthwhile to apply the FASD 4-Digit Code Caregiver Interview Checklist (Astley, 2004b)
Special Considerations for Adolescents
~ Evidence shows that adolescents will commonly exhibit learning and behavior challenges, especially in
~ Adaptive function/getting along from day to day
~ Remaining organized and regulated
~ Learning information slowly (especially what is said to them)
~ Tending to forget things they have recently learned
~ Making the same mistakes over and over.
~ Impulsivity/finding it hard to inhibit responses
~ Social communication (leaving out important details/being vague).
~ Suggestibility (and therefore easily influenced by others)
~ Immature social skills. (too friendly/trusting,/difficulty recognizing dangerous situations.
Differential Dx
~ There is some evidence for distinguishing between children with FASD and children with ADHD. Using the four-factor model of attention it has been shown that:
~ children with FASD have difficulties with encoding (taking in and processing information) and shift (shifting attention (hyperfocus))
~ children with ADHD have problems with focus and sustain. (Using Mirsky (1989) 4 factor model of attention)
~ Distinguishing between attention-deficit hyperactivity and fetal alcohol spectrum disorders in children: clinical guidelines Neuropsychiatr Dis Treat. 2010; 6: 509–515.
Suicide Intervention/Prevention for Individuals with an FASD
~ Standard suicide assessment protocols need to be modified to accommodate neuropsychological deficits and communication impairments:
~ Instead of “How does the future look to you?” ask “What are you going to do tomorrow? Next week?” (Difficulties with abstract thought.)
~ The seriousness of the suicidal behavior does not necessarily equal the level of intent to die (lack of understanding of consequences).
~ Obtain family/collateral input regarding exacerbating and mitigating factors..
~ Be careful about words used regarding other suicides or deaths.
Suicide Intervention/Prevention for Individuals with an FASD
~ Intervene to reduce risk:
~ Address basic needs and increase stability.
~ Treat depression.
~ Teach distraction techniques.
~ Remove lethal means.
~ Increase social support.
Suicide Intervention/Prevention for Individuals with an FASD
~ Do not use suicide contracts (impulsivity issues).
~ Monitor risk closely.
~ Reinforce and build reasons for living. (Be literal.)
~ Strengthen advocate-client relationship.
~ Source: Huggins JE, Grant T, O'Malley K, Streissguth A. Suicide attempts among adults with Fetal Alcohol Spectrum Disorders: Clinical considerations. Mental Health Aspects of Developmental Disabilities. 2008;11(2):33–42.
Modifying Treatment (Making it Safe)
~ Even with compensatory strategies, the person with an FASD may:
~ Be less able to use judgment, consider consequences, or understand abstract situations
~ Social isolation and loneliness may drive the person to seek out any type of friendship and lead to victimization.
~ Impulsivity is an ongoing issue.
Modifying Treatment (Making it Safe)
~ Keep vigilant for situations where victimization is possible
~ Role-play personal safety and specific scenarios that people face (e.g., who is a stranger vs. who is a friend) to allow the skills practice
~ Videotape the client doing it right in the role-play so he or she can watch it repeatedly, reinforcing the lesson.
~ Establish written routines and structured time charts, and have these where they are easily seen throughout the day.
~ Provide a buddy system and supervision to help decrease opportunities for victimization.
~ Help the client find a healthy, structured environment in aftercare to help them avoid criminal activity.
Modifying Treatment cont…
~ Help the client adjust to a structured program or environment and develop trust in the staff.
~ Individuals with an FASD tend to be trusting
~ Need a great deal of structure
~ May have trouble adapting to changes in routine and to new people.
~ Share the rules early and often.
~ Put instructions in writing and remind the client often.
~ Keep the rules simple and avoid punitive measures that most individuals with an FASD will not process.
~ If a rule is broken, remind the client of the situation and help to strategize ways they can better follow the rule in the future.
Modifying Treatment cont…
~ Focus on all aspects of the client's life, not just the substance abuse or mental health issues.
~ Include basic living and social skills
~ Help the client develop appropriate goals within the context of his or her interests and abilities.
~ Provide opportunities to role-play or practice appropriate social behaviors
~ Areas of focus may include
~ Impulse control skills
~ Dealing with difficult situations such as being teased
~ Problem-solving
Modifying Treatment cont…
~ Assume the presence of co-occurring issues.
~ Include the client in treatment planning/modification
~ Build family/caregiver meetings into the plan with a clear agenda.
~ Recognize that some family members may also have an FASD
Modifying Treatment cont…
~ Incorporate multiple approaches to learning, such as auditory, visual, and tactile approaches.
~ Avoid written exercises
~ Focus on hands-on practice, role-playing, and using audio- or video-recording for playback/reinforcement of learning.
~ Use multisensory strategies (drawing, painting, music) to assist in expression of feelings & take advantage of skills that these individuals have.
~ Consider sensory issues (light, smell, sound) Individuals with an FASD can be very sensitive to these environmental factors.
~ More effort may be needed to convey basic concepts and promote a positive therapeutic relationship and environment.
Modifying Treatment
~ The following are recommendations designed to help providers:
~ Set appropriate boundaries
~ Because of social communication problems, they may breach boundaries by making inappropriate comments, asking inappropriate questions, or touching the counselor inappropriately.
~ Have the client walk through the rules and expectations and demonstrate expected behavior.
Modifying Treatment
~ The following are recommendations designed to help providers:
~ Memory Issues
~ Persons with an FASD frequently experience difficulty with memory
~ They may be able to repeat rules but not truly understand them or be able to operationalize them.
~ Limit the number of rules, review them repeatedly, and role-play different situations in which the person will need to recall the rules.
Treatment Issues
~ Be aware of the client's strengths
~ A common theme that counselors need to be attentive to is powerlessness, reflected in the following types of client communications and behaviors:
~ Clients undervaluing their own competencies.
~ Clients viewing others' needs and goals as more important than their own.
~ Clients' inability to obtain nurturance and support for themselves.
~ Clients' feelings of depression, anger, and frustration about their lives.
~ Clients' low expectations for their own success.
Treatment Issues
~ Help the client cope with loss
~ Address any self-esteem and personal issues
~ Address resistance, denial, and acceptance
~ Women with an FASD, may fear becoming like their mothers
~ People with an FASD may have difficulty with forgiveness of the birth mother
~ Reassure clients that they are not responsible for their disability
~ Help them resolve their feelings about the birth mother
~ Educate them about the science of their condition
Treatment Issues
~ Assess comprehension on an ongoing basis.
~ Ask the client to summarize what you have said.
~ Review written material, such as rules, at each session.
~ Do not assume that the client is familiar with a concept or can apply it simply because you have reviewed it multiple times
~ Have discussions that explore their understanding beyond simply being able to repeat the concept.
Group Work with FASD: Accommodations
~ Explain group expectations concretely and repeat these ideas often.
~ If a person monopolizes conversation or interrupts, use a talking stick as a concrete visual reminder of who should be speaking.
~ Give the person time to work through material concretely within the group time
~ Encourage clients to ask questions and can check understanding of material.
~ Listen for key themes to emerge slowly through the person's talk and behaviors. Selectively paraphrase and reinforce… “Exactly..and what else could you do in that situation…”
Group Work with FASD: Accommodations
~ Allow the client to get up and walk around if he or she gets restless.
~ Use concrete representations
~ Marking the floor, to show the concept of boundaries.
~ Use Legos to represent each person
~ Water to represent energy
~ Symbolic charts/alarm reminders for routines
~ Role play
~ Make adaptations for the whole group to avoid singling out the client.
Treatment Accommodations
~ If medication is used, simplify medication schedules and provide support.
~ Find something the person likes and have the person do that regardless of behavior.
~ Create “chill-out” spaces in each setting.
~ Be creative about finding ways for the individual to succeed.
~ Establish achievable, short-term goals.
~ Reconsider zero-tolerance policies.
Treatment Accommodations
~ Be consistent in appointment days and times.
~ Consider shorter, more frequent meetings or sessions.
~ Arrange for someone to get the person to appointments for at least 6 months.
~ Have the meetings on the same days each week.
~ Discuss each meeting with the person.
~ Use open meeting times, if necessary.
~ Send text reminders with permission
Treatment Accommodations Continued
~ Have pictures of the counselors on their office doors.
~ Identify possible buddies (e.g., family, friends, church or other organizations) to ensure the client gets to appointments, etc.
~ Identify persons who are appropriate supports for the client, as well as persons who are not helpful.
~ Program important numbers and reminders into their cell phone for them.
Treatment Modificaitons cont…
~ Do not use metaphors or similes.
~ Do not use idiomatic expressions and proverbs.
~ “A day late and a dollar short.”
~ “People in glass houses shouldn't throw stones.”
~ Don't use sarcasm, and be careful about joking with the person.
Summary
~ Additional modules will focus on topics including…
~ Accommodations for the clinician to prevent exasperation and burnout.
~ FASD in the criminal justice system
~ Case management and Unmet needs for caregivers