Fetal Alcohol Spectrum Disorder in Mental Health and Criminal Justice

Foreign. In this presentation, we're going to explore the scope of the problem of FASDs. I'm going to hit you with a bunch of statistics at the beginning. You don't need to know those for your test. When I put in statistics, what I really want to do is just kind of give you a better idea of what we're talking about so you can see in numerical terms the scope of the problem. Then we'll identify the impact of the impairments across life domains and discuss specific issues based on developmental stage. Well, I'll explain that more as we get there. So, fetal alcohol spectrum disorders in the DSM 5 are diagnosed as neurobehavioral disorders associated with prenatal alcoholic speech exposure. That is a big old mouthful. And I'm not sure why they rejected FASD since that is the common terminology, but they did. Whatever it is a diagnosis, it requires evidence of both prenatal alcohol exposure and CNS or central nervous system involvement as indicated by impairments in cognition, self regulation and adaptive functioning. Now, if you're working in the child welfare system, for example, or if you've got, got an adopted child, you may not know if there's prenatal alcohol exposure, even if you're working with birth parents. A lot of times there is a great sense of shame that surrounds this issue. So people may not be totally forthcoming about their alcohol use during pregnancy. Just being aware that, you know, you need to use your best judgment when you're making diagnoses in terms of maternal drinking. How big of an issue is this even today? The most recent statistics, about 20 to 30% of women reported drinking at some point during pregnancy, most typically during the first trimester. So, you know, put on the screeching halt right here. Now let's think about this. If you have been pregnant, if or if your female spouse has been pregnant, when did they know they were pregnant? A lot of pregnancies are accidental. So people may be drinking during their first trimester because or and not know they're pregnant. We need to make sure that we wrap our head around this because we don't want, want to seem like we're shaming or blaming people for drinking, especially during the first trimester when they didn't know they were pregnant. You know, a lot of times you're six, eight weeks along before you actually realize. Or people are six or eight weeks along before they actually realize they're pregnant. And people who have irregular cycles may actually be, you know, almost through the first trimester before they finally take a test and realize they're pregnant. So it is important, important to recognize that unfortunately, during the time when the brain is most susceptible to damage, people may be consuming alcohol or drugs. More than 8% of women have reported binge drinking at some time during their pregnancy. Again, most typically during the first trimester. And it can be, you know, a lot of times we don't know the exact moment of, or the exact day of conception. So they may not exactly know when they got pregnant pregnant. You know, maybe they were binge drinking, they went on vacation, and they know they got pregnant when they were on vacation at some point during that time, but they also were partying it up. So that would fall within these statistics here. Almost 10% of pregnant women reported drinking alcohol in the previous month. So 1 in 10 women still continues to drink. And even after they know they're pregnant. Almost 5% of pregnant women reported binge drinking in the previous month, which is defined as four or more drinks in an occasion that could be. And, and remember, when we're talking about, for example, a glass of wine, you know, we're only talking about a couple ounces. We're not talking about a big glass, we're talking about a couple ounces. So four or more of those in a sitting or in a, in an occasion would count as, quote, binge drinking. This is important because it helps us understand why we have such a high prevalence of fetal alcohol spectrum disorders. It also helps us do some preventative education of, you know, people that we are working, people that we are working with to help them understand the importance of not drinking or stopping drinking if they are consuming alcohol at any point in their pregnancy. The National Institute on Alcohol Abuse and Alcoholism estimates the prevalence of fetal alcohol spectrum disorders. Now, just like autism spectrum disorders, FAS is on a spectrum. The prevalence in the general population is about 5%. Or 1 in 20 people has some level of fetal alcohol spectrum issues. Just kind of let that sink in for a second. 1 in 20. Now think about how many children are in a classroom, generally 20 or more. So at least one child in a classroom is probably going to have some level of fas. Think about the people you work with. You know, if you work in a clinic that has 20 people employed, chances are, you know, if we just go with this, one of those people may have some level of fetal alcohol spectrum issues. 94% of individuals with an a fetal alcohol spectrum disorder also have one or more mental illnesses. And this can include adhd, autism spectrum mood disorders, you know, a variety of things, addictive behaviors, 70 to 73 to 80% of children with full blown fetal alcohol spectrum issues are in foster or adoptive placement. Now that is heartbreaking. 73 to 80% of those children who, who are diagnosed with FAS. And when we talk about full blown FAS, we're talking about children who have facial features that are representative of FAS. They have the most severe levels. 61% of adolescents with FASD experience significant school disruptions. And we'll understand why in a minute. It's also important to remember that fetal alcohol spectrum disorders are often intergenerational. If a parent, birth parent is, has an fasd then that may impact their ability to understand the consequences of their behaviors, to foresee future consequences and to manage impulses. As a result, they may be more likely to drink when they are pregnant. Additionally, when people are, you know, if once they have their children, if that child has an FASD or some other issue that you're working with the family, it's important to remember that the caregiving parent that also has an FASD may need modifications to the treatment plan because they're not going to be able to be compliant like we would necessarily expect. They're going to have challenges with treatment plan compliance. And we want to make sure we don't see this as resistance. We see it as a something that needs accommodation. The prevalence of F FASD in the child welfare system is 17 to 19 times higher than in the general population. 12.8 is the average age that children with an FASD begin having trouble with the law. And 60% of people with an FASD do end up having a history of trouble with the law. And you'll understand a little bit more why might be later FASD. Remember I said that the DSM 5 has a whole different term for it. FASD is not the diagnostic term, but it's an umbrella term encompassing four categorical diagnostic entities. Fetal alcohol spectrum disorders. Which is the most severe? Partial fetal alcohol syndrome, alcohol related neurodevelopmental disorder and alcohol related birth defects. And that goes from most severe to least severe. When you are trying to diagnose an fasd, you're going to have the input. It's going to be a multidisciplinary team with a pro, usually a neurologist and a psychiatrist, pediatrician. There's a lot of people that are necessary to get an accurate assessment of the needs of a, of a child who has a fetal alcohol spectrum disorder. So let's talk about the impact of the functional impairment. There are problems in multiple domains that interfere with treatment and life success. And that's really where we come in. There are certain things, you know, we can't rewire their brain, but we can help the person through providing interventions to help them manage their presenting issues. They may have difficulty remembering program rules or following multiple instructions. And this goes through adulthood. It's not just, you know, when you're talking about children. So when they're at work, this may be a problem because they may need to have instructions broken down for them. They may need to have rules posted. Now, obviously, you know, the more severe the fetal alcohol syndrome is, the more symptoms, typically the person has, the more issues they're going to have neurodevelopmentally. So not everybody is going to need this. But it is important to understand that if somebody has an FAS or an fasd, it's going to be important to identify, okay, do they have difficulty remembering the program rules? You know, they're not being oppositional, they're not being defiant. They just keep forgetting. And one of the hallmarks of an fasd, especially in the criminal justice system, you'll look at their, their, their rap sheet, their arrest history, and it's the same thing over and over and over again. And usually it's petty crimes, you know, very rarely are. Is it significant? But we're going to talk in a minute about the fact that people with fetal alcohol spectrum issues tend to be very gullible and they want to please, and they tend to be very easily manipulated. So if they fall in with the wrong crowd, they can very easily start developing problems with the law. Additionally, you know, a lot of times you say, well, you know, when they hear that, can't they, you know, recognize that that is the wrong thing to do and it's going to end up getting them in trouble? And the answer is no. They have difficulty anticipating consequences, even if they've done the same thing 17 times before. And it's hard for us to wrap our heads around that because that's so different from the way we process information. When we experience something, typically we learn from it and we modify our schema and adjust future behaviors accordingly. Not so with people who have fetal alcohol spectrum issues. So if they're having difficulty following rules or following multiple instructions, it's important to post the rules and give instructions. Instructions, one at a time. Write the instructions down in order to make sure that they can, you know, they can follow a list, they can follow a checklist. They may have difficulty remembering and keeping appointments or get lost on the way there. They've been to your office, you know, every Every week for six months, but they can't remember how to get there every single day. It's like they're coming for the first time. And, and they also have difficulty remembering appointments. You schedule something today for a week from today, they're not going to remember it. Most people have difficulty remembering an appointment a week from today, but they have even more difficulty doing it. So it's important to make sure they have additional prompts, whether it's push notifications that are automatically set up up to prompt them to do things, to go. And this is not just appointments, like doctor's appointments, but this is meetings at work, this is going out to dinner with your significant other. They may need to have those things anytime you make an appointment or a date of any sort, that may need to be converted to a push notification, something on a calendar that it. So they're automatically notified ahead of time. And for some people, if they have more severe fetal alcohol syndrome, they may need prompts to remind them, okay, you're going out to dinner with your friends tonight. You need to. And have, have a, a push notification an hour and a half ahead of time that says you need to take a shower. You need to remember to, you know, brush your teeth, put on deodorant, whatever it is, and really actually step them through it. Whatever you can do to increase their independence is going to be really helpful. Now, some people with fetal alcohol syndrome can't live independently, but some can, and it's important to figure out, you know, with technology, there are a lot of ways we can help them live more independently and feel more empowered. They may have difficulty independently making appropriate decisions about treatment needs and goals. Well, goal setting is making a plan for something in the future. If they have difficulty anticipating consequences or anticipating what they're going to need in the future, then they may have difficulty identifying what they need right now. It's going to be important to walk them through it, write it down, you know, talk with them about what they want. And sometimes you may need to involve a legal guardian in treatment decisions. Particularly, a lot of people with fetal alcohol spectrum issues have difficulty appropriate, appropriately interpreting social cues, often interpreting them as being more intimate than they really are. This is another area where people with fetal alcohol syndrome may have difficulty because in, in relationships and interpersonally at work, because they may invade other people's space or they may perceive relationships as more intimate than they really are. So it's really important to role play with people, you know, Yes, I know. I just said they can, they don't learn, they don't modify their schema, but it's still important to go through it. Your people who are on the extreme end with fetal alcohol syndrome may not ever be able to adapt. But along that continuum, you know, there are things that people can do. You know, if it's not as severe, they may actually be able to adapt somewhat, especially if they repeatedly rehearse what you're talking about. They repeatedly rehearse social interactions, for example. So just like people with autism, you don't want to assume that people with fetal alcohol syndrome or fetal alcohol spectrum disorders are all the same. You don't want to assume that you know what they can and cannot do. It's going to be important to assess what the individual can do because everyone is very different. People with FASDs have difficulty observing appropriate boundaries and that can be true with staff, other clients at work, in the grocery store. So this is an area that's really important to regularly rehearse. And if they are having difficulty with in this area, that is one of the most common reasons that they may need to have 24 hour care or have care outside of the home in order to ensure that they maintain appropriate boundaries. That's even more true now when we're talking about social distancing, which, you know, a lot of people who don't have FASDs are having difficulty remembering that whole six foot rule. They may have difficulty attending to and not disrupting group activities. This can be circle time for kindergarteners, it can be class for elementary school kids or, or adolescents. It can be work or work meetings for adults. And it's really important to remember they have difficulty with impulse control and disruption and that it's not that they're trying to be mean. You know, and this is something that we talk about a lot with people with adhd, for example. They're not trying to be mean disruptive. It is an impulse control issue. And that is one of those things to look at with each individual and see any triggers you can identify what things might prompt this person to be more disruptive. In a meeting, if they're hungry, if they don't remember to go pee before the meeting, what things can you mitigate that may enhance their success? And in group activities, remembering that people with fetal alcohol spectrum issues may not be able to focus for an entire hour or an entire meeting, they often have difficulty processing information readily or accurately or acting their age. And I think we're going to talk about it in a few minutes. But another one of the hallmark characteristics of fetal alcohol spectrum issues is that they often can talk a good talk. They may talk at a level higher than their developmental level and it sounds, you know, great. They are very inquisitive. But what they receive and what they can interpret, what they get back is often at a much, much lower level. So they may talk at the level of a 18 year old and receive on the level of an an 8 year old. We have to adjust our communication accordingly. And again, each person is different, so we don't want to talk down to them. But we also do need to recognize for each individual at what level their receptive communication is at. When indicators occur in any of these domains, and particularly if you notice they're occurring across multiple domains, there is a FASD caregiver interview checklist and you can click on that hyperlink and learn more about that. If you happen to work with people, which you probably do, who have some level of a fetal alcohol spectrum disorder, evidence shows that adolescents will commonly exhibit learning and behavior challenges, especially in adaptive functioning and getting along from day to day. Now, remember when, think back to when you were in school and the first couple of days of school were really kind of nerve wracking because you didn't have your routine down, you didn't know when you were going to your locker, you didn't know which classes you were going to, you had to find your way around. Or for, you know, elementary school kids, you know, they still have to develop their routine with each beginning school year. For a person with fetal alcohol spectrum issues, they may never actually find that routine. They may never get into a groove, so to speak, because every day is kind of like Groundhog day. It's kind of like new again. So we do need to make sure that the people that are providing care are able to prompt them. For adults, the same thing is true. Provide them with schedules so they can look at it and they know, okay, this is what I need to do instead of wondering. Because they may not remember from day to day, even if they do the same thing every day, they may not remember they have difficulty remaining organized and regulated. And by the way, are you hearing a lot of similarities between ADHD and fetal alcohol spectrum issues? There is a lot of overlap in symptomatology and it's really important to effectively differentially diagnose because there are some things that are very different, for example, the receptive speech. But it is also important to address the presenting symptoms, for example, remaining organized and regulated. You know, that intervention is going to be very similar for ADHD and for people with FASDs. So we need to figure out based on what they do on a day to day basis, how can we help them stay organized, what works for that particular person. Maybe you need to help them put together their outfits at the beginning of the week. So they just have to pull off a hanger and it's got everything they need from their skivvies and, and including their skivvies and their shirt and their pants or skirt and shoes or whatever. All they've got to do is pull that off the hanger. They don't have to try to think about what do I need to wear? And how is that going to fit with the weather outside. You know, in Tennessee we say, if you don't like the weather, wait 10 minutes, it'll change. And you know, people with fetal alcohol issues may not anticipate that it's going to be warm outside. So they may open their closet and see, oh, I want to wear this great big old wool sweater and not really register that, you know, it's going to be 80 degrees today and you're going to be really uncomfortable. So it is important, you know, for example, with clothing, when, when you're working with somebody with a fetal alcohol issue who may have difficulty learning and may have difficulty organizing and things like at the end of winter, put away the winter clothes so that they're not even there to be tempting to wear. And the person has a better shot if they're picking their own clothes of getting something that is weather appropriate. They may have difficulty learning information and they may learn a lot more slowly, especially what is said to them. A lot of the impairment in fetal alcohol syndrome and fetal alcohol spectrum disorders is in auditory, what the receptive speech that they're hearing. Obviously if they're receiving it, they're hearing it. Sorry. But it's important to recognize that if you are presenting information orally, like in staff meetings, like in grade school, where the teacher's standing up there and lecturing, like in relationships, you know, when somebody, or even in counseling, when we are primarily communicating verbally, it is harder for the person to learn and it's going to take them longer. We need to break it down into smaller chunks, repeat it more times, and generally you're going to have to repeat it over successive days. It's helpful if you can also have them apply it, you know, act it out, role play, do something like that, as well as give it to them visually so they can read it and, and rehearse it themselves. Also, watching videos is very helpful for people with fetal alcohol issues. If you want to have them learn a skill if it is modeled in a video. Having them watch those videos can be very, very helpful. Especially if there's a, a voiceover saying, you know, this is what Jane is doing. I don't know if you remember, I'm pro, I'm probably gonna date myself here. But back in the day we used to have these videos that they would show us in health class and science class and home, home economics. And it, there was a narrator that was talking about what, you know, the person was doing and you know, supposedly teaching us what we were supposed to be doing. But you know, the black and white, real reel based movies aside, you can still do that in order to model particular information and help people learn. You can also record them while you are, while they are doing a role play with you and have them watch that recording of themselves over again as homework. They may tend to forget things that they've recently learned. This is not being oppositional or being challenging. And this is important especially in school. Well, and in work because the teachers, the supervisors make it very frustrated if you just taught somebody something or you, you know, they just learned something and the very next day they can't remember how to do it. And it's important that they understand the caregivers, so to speak, what the person's capabilities are and ways to intervene so in on successive days. Especially if you have it written down in a checklist, it may be easier to just review it real quick instead of having to reinvent the wheel. The person may make the same mistakes repeatedly. Remember I said they do not typically learn from experience and modify their schema to guide future behavior. So they may continue to make the same mistakes. And it is challenging it for caregivers, for supervisors, for loved ones of people with FASDs. When this happens because, you know, it, it feels sometimes like they aren't trying, but they are. There may be difficulty with impulsivity and finding it hard to inhibit responses, blurting, taking their turn, those sorts of things like you also see in adhd. There's mood liability which can make sense. That kind of goes along with impulsivity. When they feel happy, it's just like woohoo. And when they feel sad, they may be very emotive and they may be very sensitive and, and their mood may shift throughout the day. They may have difficulty with social communication, leaving out important details or being vague partly because they may not remember or they may not be able to anticipate, you know, what they're going to be doing when they go on vacation. If you ask them, you know, what did you do when you went to Disney World last week? You know, they may not remember all those details. So you may get this vague thing like, you know, we stood in line a lot or something. And likewise, if you ask them, what are you going to do when you go to Disney World? It may be very vague because they can't anticipate. They have difficulty conceptualizing what the possibilities might be. They are, they do tend to be very suggestible and very easily influenced by others. So it is important to, as caregivers, as teachers, you know, whomever, to provide extra special care to help guard against influences that might be malicious. And they often have immature social skills. They're too friendly, trusting, and have difficulty recognizing dangerous situations. There is a and. And I'm not sure why people with fetal alcohol syndrome tend to be wired this particular way so frequently. It's obviously, it's a common characteristic that they do tend to be very loving, very trusting, and very, very gullible. So we do need to observe that. And in some ways we may explore how interesting life might be because they are, you know, optimistic. They aren't as pessimistic, they aren't as suspicious of other people because they haven't. They don't remember negative experiences as being negative. You know, it just kind of, it happens and it goes away. Okay? Differential diagnosis of people with FASD and ADHD can be done using the four factor model that was proposed by Mirsky in 1989. People with FASDs have difficulties with encoding, taking in, and processing information, especially verbal, and have difficulty shifting attention. So if they're focused on something, getting their attention and getting them to shift attention may be very difficult. So during passing periods, going from a meeting to something else, you can think about and pay attention yourself to all the times that you have to shift attention throughout the day and think about how challenging that would be if you had difficulty, significant difficulty shifting attention, shifting gears. Children with ADHD often have problems with sustaining focus. Now, I put a little asterisk by that because children or people with ADHD sometimes also do have hyperfocus. If it's something they're particularly interested in, they may also have hyper focus with it. So we don't want to assume that hyperfocus is, is exclusive to people with FASDs. And remember, they also have difficulty with impulse control. So sometimes, especially if they're not into something, you know, if they're bored, if they're not engaged, they may have more difficulty with disruptive behaviors and impulse control. There is also some overlap of FASDs with autism spectrum disorders, but it's important to remember that they're different. FASDs are not considered autism spectrum disorders. So people can have both diagnoses. They can have both diagnoses plus ADHD sometimes. So we do want to effectively differentially diagnose to understand what we're dealing with. And potentially, you know, in the case of adhd, for example, there's often dysfunction in their norepinephrine system. So there are in some cases pharma, pharmacological interventions that might be helpful. Whereas with FASDs, that, that's not so much the case, but so looking at symptoms, effective differential diagnosis is important. Now, occasionally you're going to have people with FASDs that become suicidal, they become depressed, they become suicidal. And it's important to recognize that because of the difficulty receiving and encoding information, the impulsivity, the difficulty anticipating and learning from consequences, they may be at a much greater risk for suicide, for completed suicide, than people who don't have these issues. Standard suicide assessment protocols need to be modified to accommodate the neuropsychological deficits and communication impairments. When you're talking to somebody with an fasd, instead of saying, how does the future look to you? Which is one of those vague questions, they need to anticipate things. Not gonna, they're not gonna know how to answer that. Ask, what are you going to do tomorrow? What are you going to do next week? Keep it very concrete and don't expect abstract thought. The seriousness of the suicidal behavior in people with FASDs does not necessarily equal the level of intent to die. They may not be able to understand the consequences or anticipate the consequences of their behavior if they engage in something that is particularly damaging. I'm choosing my words carefully, so YouTube doesn't completely censor me. But it's important to recognize that they may not recognize the difference between. Things that could be harmful or injurious but not deadly and things that could be deadly. It's important if you're working with somebody who has an FASD who is suicidal or even clinically depressed. I, I think it's important to start early and be preventative, obtain family and collateral input regarding exacerbating and mitigating factors. You know, they are very sentient individuals and caregivers and family often will have a idea of the things that can make it worse and the things that can make it better, whereas the person with an FASD may not be able to articulate those things, even if they know them, they may not be able to articulate them. That's where family can come in. Do be careful about words used regarding other suicides or deaths because they, since they tend to be significant suggestible, it can be different than working with somebody who is, who is not as suggestible, intervening to reduce risk. Explore the meaning of the ideation with the person if they can articulate that and, and you may have to use your own interpretations from what they're saying to, and talking with you about to understand, you know, why are they considering, considering death? What would death provide for them? Escape or relief from, you know, what is it that's triggering this desire to stop the pain? Discuss tangible alternatives to deal with whatever is causing them the distress that they're trying to escape from. Address underlying precipitants. For example, a person may say, when my parents fight, I want to die, or when I am being bullied, or when so and so is mean to me, I want to kill myself. And it's important to explore, you know, those are obviously exacerbating factors that may need to be addressed. How can we address those or how can we help the person address those so they are not triggered? We need to address basic needs, including safety, empowerment and connectedness and increase their stability in their, their environment. They want to be just like anybody else. They want to be loved, they want to be safe. They want to have a sense of peace and connectedness. So we need to figure out, you know, in what areas might this be lacking and how can we enhance that. Think of Maslow's hierarchy, those bottom levels. You have your biological needs, your safety needs, and your love and belonging needs. We all need those. So how can we help address those so the person doesn't feel isolated, hopeless, helpless. Treat dysphoria. And you know, this can be depression, anxiety, anger, all of the above. It's important that we look at what's triggering it for that person and provide them tools to address it. And you know, in if their fetal alcohol syndrome is severe, you know, we may need to take steps through case management or, or whatever in order to advocate for the person or work with their caregiver to advocate for them in order to address some of the things that are triggering their dysphoria. Teach distraction techniques, teach them what they can do, things that they can do when they are feeling distressed. And it can be distress tolerance skills, but you want to break it down, things that are very simple, tangible for them to do, whether it's a worry stone or, you know, bouncing a ball or holding on to a, a blanket, whatever it is that helps them get grounded again can be helpful. Remove lethal means and increase safety in the environment. Remember that they may have difficulty with impulse control. So anything that's around could theoretically be a problem. And yes, this does mean kitchen knives, razors, medicines, including over the counter medicines like decongestants and Tylenol alcohol, including rubbing alcohol. But drinking alcohol as well as rubbing alcohol and matches and lighters, they may not anticipate the extent of damage that these things could do. You know, like with matches and lighters they may not be able to anticipate that that would burn down the whole house. So getting these out of access can be important, especially in people, you know, who are further along the sp in the spectrum and increase social support. People with FASDs love other people, they want to be around other people, they seek approval as I was talking about earlier. So it's important to for a lot of people with FASDs to have social support. Now, people with FASDs just like people who are neurotypical. Some will be introverts and not want to be around a whole group of people because that's exhausting. And some will be extroverts who really thrive on being in a group. And it's important to figure out what works for that individual. Don't use suicide contracts because of impulsivity and issues as well as their ability, as I said earlier, to under understand receptive language. They may agree to stuff and just have no idea what they're agreeing to. That just creates a false sense of security. Don't use them. Monitor their risk closely. Reinforce and build reasons for living. Being literal, you know, being very concrete about what they are living for. You know, their dog Sam, their, their mother, their whatever it is they like they're living for. Even have them again create a scrapbook or a video where they're talking about all of the reasons that they want to live or all the things that are important in their rich and meaningful life. Now don't use that phrase with them because that'll be confusing. But what things do you like? What things do you enjoy doing? What are your reasons for living? Is getting a little bit abstract. But you can have them build a scrapbook or like I said, record a video of them talking about it and then they can re watch themselves talk about it and strengthen and advocate in the for the client and work with a client as a client advocate relationship, encouraging them to do what they can for themselves but also recognizing that unlike some of your other Clients, they may not be able to always advocate for themselves. So it's going to be important that they have an advocate, whether it's you or somebody else that can be with them, you know, when they're not in session to modify treatment. 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, which can lead to victimization. Remembering also that impulsivity is an ongoing issue. Keep vigilant for situations where victimization is possible. Whether you are a caregiver or a clinician, and this is a residential treatment or drop in treatment, whatever, or a teacher, recognize that it's important for us to be vigilant for these situations and advocate and seek to be a buffer protector when victimization might be possible. Roleplay, personal safety, and specific scenarios that people face, such as who's a stranger, who's a friend. In order to allow the skills practice. Doing this, you know, one time during a group, one week, is not going to cut it for the majority of people who have Moderate to severe FASDs. This is going to be something that you've got to go over regularly. And if you're a caregiver, for example, you may go over this before they go to the park. You know, each time you take the child to the park, before you get out of the car, you role play who's a stranger, who's a friend in order to reinforce that. So it's what they've, what you're trying to communicate, what you're trying to have them learn is very proximal in their mind. Videotape the client doing it right in the role play so they can watch it repeatedly, reinforcing the lesson. And this can be cooking, you know, maybe doing laundry, making macaroni and cheese, whatever it is that you want them to do. It's not necessarily just interpersonal skills. Videotape them doing it correctly, which is great with mobile devices now it's so easy to do, and then they can watch themselves do it over and over again. Establish written routines and structured time charts and have these where they're easily seen throughout the day. This is true or can be true for adults as well as, as youth. Now obviously youth who are neurotypical benefit from this as well. But people with FASDs, people who have difficulty structuring time and, and staying organized as adults, may benefit from these things. And you're going to have to figure out based on the individual exactly how granular you need to be in these time charts. Remembering that charts are there, but we can habituate to them after a while and, and kind of overlook them. So it may also be important to have push notifications set for that person that have alarms that are associated with them. Provide a buddy system and supervision to help decrease opportunities for victimization. Now this more applies to school and counseling in group settings. But it's also important for the person, for example, if they are on, if, if they're doing, doing some sort of a job, they may need to have a buddy that helps them out throughout the, throughout the day or is there to kind of guide them throughout the day. Help the client find a healthy structured environment in aftercare so they can avoid criminal activity. People with FASDs, you know, if they get bored, if they get easily manipulated, if they're lonely, they may get. In the, they may become manipulated into engaging into criminal activity. So ensuring that the person is engaged in, you know, pro social activities, whether it's volunteering or whatever it is that they're doing, but they where wherever they are at any point in time, they are in a safe, safe environment where it's unlikely that they will be bullied or taken advantage of. Help the person adjust to a structured program or environment and develop trust in the staff. Obviously this is more geared towards school and treatment. Individuals with an FASD tend to be trusting and need a great deal of structure and may have trouble adapting to changes in routine and to new people. So this includes substitute teachers or you know, in at work, new bosses. Any sort of change may really throw them for a loop and may take a while for them to adjust. To share rules early and often. Put instructions in writing and remind the client often. And sometimes it means developing a signal where if the client starts to get, or the student starts to get off track, you, you know, tap them on the shoulder and point to the list or you have something that you do that helps them get back on track. Keep the rules simple and avoid punitive measures that Most individuals with FASDs will not process. They don't understand why you're getting angry with them because they don't understand what they did wrong. Keep it simple, one thing at a time. And if they aren't able to do it, if they aren't able to follow through, then it's important to figure out why. Now you know, sometimes they may be testing their limits, you know, just like anybody does sometimes. So it's important to navigate that and really evaluate whether the person just didn't understand or didn't remember what they were supposed to do or if they were testing a limit, but trying to provide unconditional positive regard, accepting them, providing corrective feedback, and then figuring out, okay, what do we need to change? What do we need to do differently so this doesn't happen again? And that may be incumbent upon the the caregiver or the teacher or whomever to figure out what that might be, because the person with the FASD probably won't be able to tell you what what needs to happen if a rule's broken. Remind the person of the situation and help strategize ways they can better follow the rule in the future. Focus on all aspects of the client's life, not just their substance abuse or their mental health issues or whatever is going on in in treatment. Obviously you're going to focus on their school, you're going to focus on their social support, you're going to focus on the positive things in life in addition to any presenting issues that you're seeing them for in treatment. Make sure that people with FASDs have basic living and social skills and washing their clothes, knowing how to actually wash their hair. You know, that's one of those things that I just assumed that people always knew. But you know, you have to teach them. You need to, you know, get your fingertips in there and really scrub a scrubba. Help the client develop appropriate goals within the context of his or her interests and abilities and provide opportunities to role play or practice appropriate social behaviors, including impulse control skills. You know, how do I sit through a classroom, how do I sit through church? Or if you're flying on an airplane, how do I keep from being disruptive? You can rehearse dealing with difficult situations such as being teased or just basic problem solving. What do you do when Assume the presence of co occurring issues. When you're working with people with FASDs, even if they can't participate fully, it's important to include the person in treatment planning and any treatment modifications. Build family caregiver meetings into the plan with a clear agenda, remembering that it wouldn't be surprising if one or more of the family members also had an fasd. So you may need to adjust the family treatment accordingly. Incorporate multiple approaches to learning such as auditory, visual and tactile approaches. Talk to them about it, let them read about it, let them see somebody doing it, and then have them actually do it themselves. Avoid exercises that are completely written like fill in the blank activities or writing a an essay that is going to be would not work For a person with an fasd, focus on hands on practice, role playing and using audio and video recordings for playback and reinforcement of learning. Use multi sensory strategies like drawing and painting and music to assist in expression of feelings and take advantage of skills that these individuals have. They have a lot of skills. It's just a matter of adjusting the environment from a neurotypical one to a neuro atypical one. And multisensory is not just auditory or visual. You also can include smell and those sorts of things. Figure out how to make it multi dimensional. Consider sensory issues like light, smell and sound. Individuals with FASDs, like people with autism, can be very sensitive to these environmental factors. Flickering lights, lights that are too bright, glare, noxious smells. Be aware that that may be distracting and very unpleasant for them. They also, because of these sensory issues, may be more sensitive to touch. And even giving them a hug or grabbing their hand may be painful or traumatic for them. So we do want to recognize that if their perception of sensory stimuli is intensified, that any environment could be very traumatic for them. Going to the, to the airport, for example, o' Hare Airport in Chicago, you know, it is bustling. It is, you know, there's lots of stuff going on and that can be very similar, scary and traumatic for a person with an fasd, for a child, for an infant or toddler with an fasd. Again, if they are hypersensitive to certain sensory stimuli, then the, the, the environment could feel very intrusive and very painful and traumatic to them. So we do need to be sensitive to that. When working with somebody with an fasd, more effort may be needed to convey basic concepts and promote a positive relationship and environment. Figuring out, you know, sometimes it is a, an experiment or a, you need to get into it and be curious about, okay, how can I teach this concept in a way that this person can get it? Because, you know, the traditional way. I remember teaching my daughter, she doesn't have an fasd, but teaching her math. She processes things far differently than I do. So it was always a challenge when we were doing math work to try to figure out, okay, how can I communicate this to her in a way that's meaningful to her? Recommendations for Providers Set appropriate boundaries. Because of social communication problems, clients may often breach boundaries by making inappropriate comments, asking inappropriate questions, or touching the counselor, person, boss, whomever, inappropriately. So it's important to set those boundaries and enforce them. You know, kindly enforce them, but enforce them. Reminding them that, you know, the, it's not okay to, to hug your boss or something. Have the client walk through the rules and expectations and demonstrate the expected behavior, frequently reminding so they remember what's appropriate and what they're supposed to do. People with FASDs frequently experience difficulty with memory and may be able to repeat the rules. You know I said they can talk a good talk but not truly understand them or be able to put them into practice practice. So it's important to have them show you what you're asking them to do. Limit the number of rules, review them repeatedly, and role play different situations in which the person may need to recall the rules. Be aware of the client's strengths A common theme that we need to be attentive to is powerlessness, which is reflected in the following types of client communications. People with FASDs often undervalue their own competencies, view others needs and goals as more important than their own, are unable to obtain nurturance and support with themselves, so they tend to be very passive. They have feelings of depression, anger and frustration about their lives because they feel often misunderstood, disempowered, unsafe, and may have low expectations for their own success, often because that's the message that they have always gotten. So we want to work to empower them and counter these problems in perceptions. Help the client cope with losses and address any self esteem and personal issues and address resistance, denial and acceptance. Women with an FASD may fear becoming like their mothers, so we may have to treat that. People with an FASD may have difficulty with forgiveness of their birth mother. That is a therapeutic issue. Reassure clients that they are not responsible for their disability. They are responsible for, you know, doing the best that they can, but they're not responsible for their disability. Help them resolve feelings about their birth mother and educate them about the science of their condition. Assess their comprehension on an ongoing basis, asking them to summarize what you've said. Review written material such as rules at each session. Don't assume that the client is familiar with a concept or can apply it simply because you've reviewed it multiple times already and have discussions that explore their understanding beyond simply being able to parrot the concept to you, have them apply Apply it, explain it in group work, explain group expectations concretely and repeat these ideas often. Same thing for classroom if a person monopolizes conversation or interrupts, use a talking stick as a concrete visual reminder. Give the person time to work through material concretely within the group time and encourage them to ask questions and check understanding of their material their understanding of the material. Listen for key themes to emerge slowly as they talk about what's going on and selectively paraphrase and reinforce what you're hearing. So if they say something that seems like they're getting it, be like, exactly, and what else could you do in that situation? Or what else does that mean? Allow the client to get up and walk around if they get restless. And use concrete representations such as marking the floor to show the concept of boundaries. Use Legos to represent people. You may use water if you're trying to explain energy. Make adaptations for the whole group to avoid singling out the client if medication is used. Simplify medication schedules and provide support. So try to get them if they can take everything at, you know, three times a day instead of having something every hour, they've got to take, you know, obviously the doctor is going to do most of that. Find something the person likes and have the person do that. Regardless of their behavior, even if they're having a bad day, it's important that they are able to have some positive time. Create chill out spaces in each setting, at school, at home, in the car, even at the park. And be creative about finding ways for the individual to succeed. Establishing achievable short term, micro term goals. It may even be like an hour. And reconsider any zero tolerance policies, remembering that people with an FASD are probably going to make mistakes. Be consistent in appointment days and times and consider shorter, more frequent meetings or sessions. Arranging for somebody to get the person to appointments for at least six months so you know that somebody else is going to be bringing them. Have the meetings on the same day each week. Discuss each meeting with the person. Use open meeting times if necessary, which may mean drop in when you need. That may not work for you. And obviously with permission. You can send SMS reminders if you're working in a group setting or like at school. Have pictures of the counselors or teachers on their office doors. Identify buddies to ensure the client gets to appointments, to class, wherever. Identify people who are appropriate supports for the client as well as people who might not be helpful. And program important numbers and reminders into their cell phone for them. Remember, they are very literal, so do not use metaphors or similes or idiomatic expressions like a day late and a dollar short. And avoid using sarcasm because they don't understand it. They are very literal. People with normal development have the ability to evaluate their own behavior in relationship to the future and understand consequences. People with an FASD often lack of connection between their thoughts, feelings and actions. With people with FASDs, it's important that we use repeated skills training with role playing and videotaping and really reconsider those zero tolerance policies. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allce.com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allce.com sponsor thank you.