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Fetal Alcohol Spectrum Disorders
Presented by: Dr. Dawn-Elise Snipes
Executive Director, Counselor Education
Host: Counselor Toolbox Podcast

CEUs/OPD/CPDs are available for this presentation at for clinicians in the US and for clinicians in Australia.

~ Define FASDs
~ Identify prevalence of FASDs
~ Identify areas of over-representation of people with FASDs
~ Explore the impact of FASDs on the person and intergenerationally
~ Discuss interventions and modifications to assist the person with a FASD
What are FASDs
~ A disorder that occurs along the spectrum which ranges from full-blown Fetal Alcohol Syndrome to Neurodevelopmental Disorder-Prenatal Alcohol Exposure (ND-PAE) β€œOther Specified Neurodevelopmental Disorder,” code 315.8 in the DSM V
~ Fetal Alcohol Syndrome (FAS)
~ Partial FAS (pFAS)
~ Alcohol-Related Neurodevelopmental Disorder (ARND)
~ Alcohol-Related Birth Defects (ARBD)
~ 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 FAS are in foster or adoptive placement
~ 61% of adolescents with an FASD experienced significant school disruptions
~ The prevalence of FASD in the child welfare system is 17 to 19 times higher than that in the general population in US (meta-analysis published online September 9 in Pediatrics).
~ 60% of people with an FASD have a history of trouble with the law
~ 12.8 is the average age children with an FASD begin having trouble with the law. (

~ People with FASD may have difficulty in the following areas:
~ Learning and remembering
~ Understanding and following directions
~ Shifting attention
~ Controlling emotions and impulsivity
~ Communicating and socializing
~ Performing daily life skills, including feeding, bathing, counting money, telling time, and minding personal safety
~ Tendency toward explosive episodes, often triggered by
~ Sensory overload
~ Slower rates of processing the information around them
~ Feeling β€œstupid”

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).
Chronological vs Developmental
~ Chronological Age ————————————————————–18
~ Physical Maturityβ€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”18
~ Developmental Level of Functioning——————–9
~ Daily Living Skillsβ€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”11
~ Expressive Languageβ€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”23
~ Receptive Language——————————–7
~ Artistic Ability (or other strength)————————————————–29
~ Reading: Decodingβ€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”β€”16
~ Reading Comprehension———————–6
~ Money and Time Concepts————————–8

Members of the Team
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 sustaining attention. (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.

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 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.
~ β€˜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)
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 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.

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
~ 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.
~ Keep things simpleβ€”Break instructions down in to smaller parts
~ Use charts and reminders
~ Minimize distractions
Modifying Treatment
~ 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.

Modifying Treatment
~ 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 β€œchill-out” spaces in each setting.
~ Be creative about finding ways for the individual to succeed.
~ Establish achievable, short-term goals.
~ Reconsider zero-tolerance policies.
Modifying Treatment
~ 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

Modifying Treatment
~ 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.
~ Assess comprehension on an ongoing basis.
~ Ask the client to summarize what you have said.
~ Review written material, such as rules, at each session.

Modifying Treatment
~ 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.
~ Do not use metaphors or similes.
~ Do not use idiomatic expressions and proverbs.
~ β€œA day late and a dollar short.”
~ β€œPeople in glass houses shouldn't throw stones.”
~ Don't use sarcasm, and be careful about joking with the person.
Modifying Treatment
~ 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.

Treatment Issues
~ Be aware of the client's strengths
~ A common theme that caregivers need to be attentive to is powerlessness, reflected in:
~ 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
~ 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
~ Educate them about the science of their condition
Other Tips
~ Expect to repeat things many times in many ways. Clients with an FASD may ask the same question every time you see them because of their cognitive deficits
~ Use a written journal or goal sheets to remind people how far they've come and where they are headed, and focus on what the person has accomplished, rather than on goals yet to be met.
~ Realize that there is no set approach; what works one time may not work the next. Clients may experience things differently day to day or even hour to hour, and variability is the norm. Keep an open mind and be flexible. Avoid statements such as β€œBut it worked last time.”

Top Unmet Needs for Caregivers