Select Page

Fetal Alcohol Spectrum Disorders in Mental Health
and Criminal Justice
Instructor: Dr. Dawn-Elise Snipes
Executive Director, Counseling Continuing Education
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

CEUs are available for this podcast at
~    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

~    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. (
~    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.
~¬†¬† ¬†‚ÄėAct one's age.‚Äô
~    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‚Äď515.

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 ‚ÄúHow does the future look to you?‚ÄĚ ask ‚ÄúWhat are you going to do tomorrow? Next week?‚ÄĚ (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‚Äď42.

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‚Ķ ‚ÄúExactly..and what else could you do in that situation‚Ķ‚ÄĚ
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 ‚Äúchill-out‚ÄĚ 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.
~¬†¬† ¬†‚ÄúA day late and a dollar short.‚ÄĚ
~¬†¬† ¬†‚ÄúPeople in glass houses shouldn't throw stones.‚ÄĚ
~    Don't use sarcasm, and be careful about joking with the person.
~    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