Fetal Alcohol Spectrum Disorders (FASD) What Is It and How to Cope

I'd like to welcome everybody to today's presentation on Fetal Alcohol Spectrum disorders. I'm your host, Dr. Donnelly Snipes. Today we're going to define fetal Alcohol spectrum disorders for those who are unaware. We will identify the prevalence of FASDs, identify areas of overrepresentation of people with FASDs, explore the impact of them on the person and intergenerationally because yeah, unfortunately we do see FASD in families partly because of the consequences of an fasd. And we'll, we'll look at that in a few minutes and we'll discuss interventions and modifications to assist the person with an fasd. Now, I want you to think about the different settings in which people may exist with FASDs. And let me tell you, it's every setting. It could be your workplace. It definitely the jails. You have youth with FASDs in schools, you have youth with FASDs that are in after school programs. So it's important, no matter what your line of work is, if you're working with human beings, that you're somewhat aware as a supervisor, if you have subordinates who have some level of fasd, okay, there are interventions that we can use. You can also go to askjan.com I think it may be askjan.org I always forget, but that is the Reasonable Accommodation network. And if you have questions that for a particular employee about reasonable accommodations that you may be able to or required to make, you can go there and get some resources and hopefully I'll provide you some today that are also useful. FASDs are a disorder that occur along a continuum, along a spectrum. Hence the name Fetal Alcohol Spectrum disorders. In the DSM 5TR, it's diagnosed as neurodevelopmental disorder, prenatal alcohol exposure, or NDPAE. Why we can't just call it FASD, I don't know, but we don't. Fetal Alcohol Spectrum Disorder has a range. You have fetal Alcohol syndrome, partial fetal alcohol syndrome, alcohol related neurodevelopmental disorder, and alcohol related birth defects. Ultimately, as I say in a lot of my videos, the label doesn't really matter. What we want to look at is the individual and what strengths they have in addition to what other challenges they might face that we can help them mitigate. Fetal Alcohol Spectrum disorders are frequently misdiagnosed as attention Deficit Hyperactivity disorder because their symptom profiles often overlap, particularly with traits like hyperactivity, impulsive behavior, poor organization, time blindness and attention difficulties. So you're looking at FASDs and you're going oh my gosh. So you know, how do you differentiate? Well, it's part art, part science. Some differences between FASD and ADHD. FASD affects about 1 in 20 children in the U.S. all right, let that sink in. So think of a classroom. You've got 20 kids in the classroom. One of them may have an FASD and they may not be in a special education classroom. They may not be in sequestered. Hopefully they're not. Hopefully we've been able to mainstream. But it's important to recognize that FASDs are prevalent. ADHD, on the other hand, affects about 1 in 10 or twice as many children. So most children, most children with a fetal alcohol spectrum issue will have a diagnosis of ADHD. They it's about 80, 85%. But not all children with ADHD have fetal alcohol spectrum issues. So a person can have ADHD all by itself and of course we need to address it. But the person who has FASD and ADHD will require some slightly different interventions. FASD does not have specific treatment options, I. E. Your stimulants like methylphenidate are not going to help with the FASD part of what's going on now. It may help if the person has concurrent adhd. The st, the psychostimulants may help with the ADHD symptoms. But again, we want to recognize that you can't treat them the same because they're not the same. People with FASD may have issues with speech, language and memory. And I've got a little table for you in a minute. People with ADHD typically do not. So that's one of the big differentiators that we're going to look at is receptive language, expressive language. Those things have significant differences in people with FASDs where we don't see that in ADHD. There is some evidence for distinguishing between children with FASDs and children with ADHD using what they call the four factor model of attention. Children with FASDs have difficulties with encoding, taking in and processing information a lot of times, and I'm jumping ahead, but that's okay. A lot of times they will talk a big talk and they can talk at the level of their, their developmental age, but what they're understanding is much less. And that's because they have learned what to say, they've learned through rote memorization. This is how I'm supposed to respond to this. Children with FASDs have difficulty with shifting attention and hyper focus. Now I know some people with ADHD have hyperfocus too. Children with fasd, hyperfocus is what's going on. Most of the time, children with ADHD hyperfocus is only around, typically only around preferred or highly stimulating activities, getting that dopamine rush going on. So if the child has or the person has difficulty shifting attention, and I want you to think in the workplace, if you have somebody who is one of your subordinates, maybe they're working at a restaurant and they're doing one task and you need them to do something else, but they have difficulty shifting. It's just like it throws them into a tizzy when they have to suddenly change activities. That may be an fasd. Now, obviously you're, as a supervisor, you're not going to be diagnosing your employees. My point is to drive home the notion that people with fetal alcohol exposure are everywhere and we just need to be sensitive to what's going on. Instead of thinking of them as disorganized or resistant or challenging, we want to look at behavior communication and ask ourselves, why is this person having difficulty doing what I need them to do? Children with ADHD typically have problems with focus and sustaining attention in the things that they're doing. The prevalence of fetal alcohol spectrum issues in the general population, depending on what study you use, and depending on the population, ranges from 2 to 8% for the entire continuum of FASD. Now, that's a little bit different than 1 in 20, but it's about about the same. 94% of individuals with an FASD also have a mental illness or more. As I mentioned, the statistics indicate that about 80 to 85% of people with FASD or fetal alcohol spectrum issues likely have adhd. But we also see anxiety, we see depression, we see trauma issues because people with FASDs are no different than other people when they feel unsafe and powerless, when they feel rejected, when they feel criticized, it can be very traumatic to them. 73 to 80% of children with an FAS are in foster or adoptive placement. Now, let that sink in for a second. So one of the things that you can do, and obviously it's only going to be right about 73% of the time, if you have somebody that you suspect may have a fetal alcohol spectrum issue, one of the things you can do is ask if they were in foster care or involved in the child welfare system. That's not going to be diagnostic by any means. But they find that because in many households, one of the contributing factors for having the child removed is substance use, that FAS occur much more often in youth who are in foster or adoptive placement. 61% of adolescents with a fetal alcohol spectrum issue experience significant school disruptions. You're going to understand why that is in a minute. Part of it may be going in and out of foster care and getting bounced around between schools if you're not able to stay in the same system. But school disruptions can also be because of behavioral issues or difficulty in succeeding. In our neurotypical school system. 60% of people with an FASD have a history of legal issues, so 40% don't. They haven't been involved with the law at all, but 60% do. All right, well, that's interesting. So we, we may want to look at youth in foster care or in the child welfare system and people who, especially youth who have gotten involved with the criminal justice system. We may start wanting to look at that as a clue that maybe there's something else going on and that can be remediated, that can be mitigated in order to empower these people to live their richest and and highest quality of life. Nearly one third of people who are incarcerated. I know, let that sink in. One third of people who are incarcerated have a fetal alcohol spectrum issue. That is a lot. And when we get to some of the characteristics in a minute, get out of these statistics, it's going to kind of drive home why it's so important for corrections officers, for police officers, for child welfare caseworkers, teachers, therapists, doctors, nurses, you know, anybody who works with a human being to be aware of fetal alcohol spectrum issues. Because in criminal justice systems, you know, jails, prisons, etc, the person with the FAS or FASD may have more difficulty surviving without interventions. 12.8 is the average age children with an FAS begin having trouble with the law. So just before 13 years old, we start seeing youth with F.A. ss start having problems with the law. Why is that? Well, 12.8, that's when the youth start spending more time out on their own. They're not as dependent on caregivers for everything. So they're going out, they're back, back in my day, going out, riding their bikes and doing that kind of thing. But they are not spending as much time in the house with their primary caregiver. Okay, this is the chart I've been telling you about. When you have someone with an fas, just like with autism, every person with a fetal alcohol spectrum issue is unique, is individual. We can't say that this particular chart is true for every 18 year old out there with a FASD. We can't, we can't even say it's True for half of them. But we can say that we know that depend where, how shall I say? Depending on where they are on the spectrum, there may be more or fewer challenges in some of these areas. So a chronicle logical age of 18, physical maturity 18. So you've got this 18 year old strapping young person just be bopping along developmental level of functioning nine. So nine years old is about third, fourth grade. 18 years old, graduating from high school. Nine years old, third or fourth grade. So you can see already where there might be problems if the person is in an adult environment like a jail or a prison or a workplace or even a treatment center. And they have an fascinating Their daily living skills are at about 11. Why are they higher? Well, because daily living skills are relatively easy for them to eventually learn to be able to do, to get up, to brush their teeth, to cook, go shopping. Now they're not going to probably be world class chefs or something. They may, but the basic activities of daily living are at about 11, the age of an 11 year old. Expressive language is often learned. As I mentioned earlier, we learn how to respond to people kind of by rote in many of our cultures. Somebody says this to you, you say that, they say, how you doing? You say, I'm just fine, thank you. You. Most people don't even think about it because they know that the person asking probably doesn't really want to know. So they say something, you have a canned response. Am I saying it should be that way? No, I'm just saying what reality is. Expressive language can be learned. So a lot of youth with FAS may actually have a higher level of expressive language than their chronological age. They may maybe because they're spending more time with adults, they don't feel like they fit in with their peers. It may be because they've just learned how to adapt and using their expressive language has helped them stay safer. Unfortunately, their receptive language, so what they understand versus what they say, their receptive language is that of a six year old that is first grade. So what they hear and they interpret and they understand is much different than what they say. So there can be a lot of confusion and imagine how scary that is to I know what I know what to say. I have no idea what it means, but I know what to say. The receptive language can be problematic because people with F A S's, FASDs are tend to be very gullible. They tend to not learn from their mistakes. They tend to be very, very easily manipulated. School system, jail, foster care, all of these are Places where there may be bad actors that want to take advantage of them. Treatment centers, same thing. We need to be cognizant of this. If we are a caseworker or a therapist or even a caregiver working with someone with an fasd. Now, their artistic ability or other strengths may be off the charts of not savant like necessarily, but off the charts. And they speculate that the parts of the brain that are disrupted by alcohol exposure are more in your money, time, comprehension, language area. But when it comes to artistic ability, that those areas of the brain aren't impacted nearly as much. So this is one of their superpowers. In addition to that hyper focus, which we can harness and help them use as a superpower, their artistic ability can be one of their superpowers, whether it is art or music or whatever works for them. For some it may be physical activities. We want to encourage them to explore and find their strength, find their groove. Even people who don't have an AF FASD aren't strong in everything, but almost all of us have a strength and we want to help them capitalize on that. So they feel a sense of purpose, they feel a sense of belonging, they feel they can develop a personal mission in terms of reading. Now, expressive language is talking and receptive is hearing reading. When we decode what we read, they can pick up what they're reading at about the level of a 16 year old. So you know, high school age, which is good, which is good partly because they can do it more slowly, they can do it at their own pace and they can decode what they're reading. They, they can read the words. Now their comprehension, just like when they're receiving information, they're reading words, they're decoding it. They can read you Shakespeare if you give them enough time. But their comprehension of that information and understand of what's going on is again at about the age, the level of a six year old. I'm not saying that they are. Well, because of changes in their brain as a result of exposure to alcohol, there are parts of their brain that are responsible for taking in all those words, whether they're hearing them or they're reading them and making sense of them, and that area of the brain has been damaged and we need to give people more time and time and money concepts are at about the level of an 8. And I have in the PowerPoint hyperlinked the document that has this particular chart in it so you can go take a look at it. But it's only one. And again, every person with a fetal alcohol spectrum issue is a unique individual. And we don't want to assume that Jim Bob, my, the 18 year old person I'm working with that ha has fetal alcohol exposure. I don't want to assume that his receptive language is that of a first grader. I want to find out, I want to find out where on the spectrum each one of these issues is. For Jim Bob. People with FASDs may have difficulty with learning and remembering because that means taking in the information, processing it and understanding what's going on. For me, being in math class, I hear the words and I see the professor writing stuff on the board and I'm just going, huh, huh. I'm not understanding a dagum thing and imagining what that must be like for somebody with a FASD for that to be, you know, everywhere, all the time. It's hard for them to learn and remember that it needs to go slower, it needs to be chunked and they need to check for meaning periodically. Okay, you do this step, why are you doing this step, et cetera. They may have difficulty understanding and following directions. Don't. Just like somebody with adhd, you don't want to give them difficult multi step instructions and just, you know, rattle them off and expect them to remember it ain't gonna happen. So we need to keep our instruction short and make sure that we're very clear in what we're saying almost to the point of being too specific. They have difficulty shifting attention. Adding cues can be very helpful, like a push notification. If they have a mobile device and they're wearing it. Having a push notification that vibrates when it's time for them to switch activities, that can be a clue of what they're supposed to do. And if there's something, sometimes they need a minute in between. It's like, okay, it's time to switch. So then they need to go to the bathroom, wash their hands, do something to help them switch gears. Controlling emotions and impulsivity is another challenge. Well, people with FASDs, because of those varying strengths and liabilities, if you will, life is stressful. Life is stressful. Even if they didn't already have issues with dysregulation and impulsivity that's characteristic like we see in adhd, they're under a lot of stress. They have difficulty communicating and socializing because they're receptive and expressive. Language is so different. It can be hard because they're talking a big game, but they may not be understanding what their friends are saying. So they feel lost in. In what's going on or it's not engaging because they're just kind of repeating words back. They may have difficulty effectively reading non verbal behavior. This is one of the interesting things and one of the most challenging things in some ways for people with FASDs. They, they do have difficulty interpreting non verbal behavior, often interpreting it as more intimate than it really is. So we need to help them. Some people with FASDs learn how to interpret those nonverbals and and set maintain boundaries. They may have difficulty performing daily life skills including feeding, bathing, counting money, telling time, and minding personal safety. Each person is going to be different. Some will have no problem with feeding, bathing, toothbrushing, even cooking easy meals and but they may have difficulty with counting money and telling time and other things that involve numbers. So we need to explore granularly. They may have explosive dysregulation episodes triggered by stress. Well, when you're already stressed out, it doesn't take much, you know, thinking of stress as a bucket. And every stressor adds water to that bucket. So once your bucket is full, it doesn't take much to add to that bucket to make it start overflowing. People with FASDs are neuroatypical, so sensory overload can be a huge issue for them. They may have slower rates of processing the information of what's going on around them. So they constantly feel vulnerable. They feel like they're behind the eight ball or sometimes they just feel, to use quotes, stupid. They don't feel like they fit in. They don't feel like anybody understands them and they don't feel like they are capable of understanding anybody else. They are capable, but we need to help them figure out what interventions they need to mitigate the difference between them and someone who doesn't have an FASD. Evidence shows that adolescents with FASDs will commonly exhibit learning and behavior challenges, especially in adaptive functioning and getting along from day to day. Remembering to bring their homework, remembering what to put in their book bag, remembering to bring their lunch, remaining organized and regulated. That's pretty common in ADHD too. And again, think about all of these symptoms in terms of not only FASD but adhd. A lot of you have already worked with people with adhd, so a lot of the interventions to address the ADHD symptoms or issues that someone with FASD may have, you've already got those in your toolbox, so score you're 2/3 of the way there. They may learn information slowly, especially what is said to them or even things that they read because their receptive and comprehension abilities are so much lower. But they can learn. We just have to give them the space and the time to do it. They may tend to forget things that they have recently learned. Now some of us forget things we recently learned anyway. In order to learn something, we have to take it in, we have to receive it, we have to encode it and we have to make room for it. We have to know why we care about it. And since a lot of people with FASDs have difficulty with that encoding part, they may learn it and it sticks around in that short term memory. They can do rounding, for example, but they can do rounding today, but tomorrow when they come into class, they won't be able to do it again. They'll have forgotten because they didn't encode it. They may make the same mistakes over and over again. And this is often unique to somebody with FASDs because they can't anticipate consequences. So they can't think of, well, when I did this before, when I put my hand on the stove before and it was hot and I got, I got burned, so I probably shouldn't do that again. That just doesn't even occur to them. So helping them identify what they need to do to stay safe is important. Helping them identify ways to mitigate mistakes. So if you have somebody who tends to put their hand on hot stoves, what can you do to mitigate that? If they're not going to remember that that's hot, put a cover over it. I had a cat that used to do that all the time. I had a little portable grill thing and it would be cooling and he would go and he'd put a stupid little paw on it and then he'd burn his paw and I'd have to treat it and everything. But then he did it again. I'm like, messy, really? What are you thinking? But we do want to recognize that sometimes it's just not going to click. That you can't go into a grocery store and get a candy bar and walk out with it without paying. That's going to get you in trouble. They may have difficulty with impulsivity and find it hard to inhibit responses. Just like people with adhd, there is difficulty with that filter. Social communication, leaving out important details or being vague is very common. Why? Because they haven't internalized the details. They, when they're talking, they're talking in generalizations because that helps them fit in. Those are the things that they memorized, basically their rote responses. They didn't memorize specific responses to specific Issues. They are very suggestible and easily influenced by others. And they often have immature social skills, often being too friendly, trusting and difficulty recognizing dangerous situations. So in terms of the members of the team, working with somebody with an FASD generally requires, especially in the early stages, generally requires a multidisciplinary team. There's going to be a case coordinator who is the single point of contact. They review history, current stability, assess needs of the individual and their caregivers. They help connect the person and the family to positive supports. And this can be a counselor, a social worker or a case manager. There's going to potentially be a psychologist and speech language pathologist to assess basic and higher level le, higher levels of brain functioning. Where are we in terms of receptive and expressive language and what does this individual need assistance with? Then there are physical therapists, occupational therapists and or vocational rehabilitation counselors that can work with the individual to help them assess motor and sensory issues and including sensory, motor integration and balance and gait issues, which again can be a problem as a result of some of the neurological damage that was done by the alcohol. The physician assesses dysmorphology or facial changes and physical changes, neurological findings and basic health determinants. They may also contribute to the behavioral health profile. And finally, the family navigator helps the family through the process. This is often a coach, maybe an uncertified caseworker is ideally an actual caregiver of someone with an FASD and is available to help the family connect with parent or family support and other needed resources. So they work really closely with the case coordinator in terms of impact of functional impairment. Being aware that people with FASDs are in home placements, foster care, treatment centers, schools, jails, prisons, we see them in pretty much every setting. Problems in multiple domains interfere with the person's success, including inability to remember program rules or follow multiple instructions. What do we need to do? Write it down, post it so they can have visual reminders, use pictures and I summarize that at the end. Remember and keep appointments or get lost on the way there. A lot of people with FASDs just totally blank out. Or they have difficulty remembering without having push notifications, remembering that hey, at 9 o' clock I've got to do this. They have difficulty independently making appropriate decisions about their personal needs and goals, including treatment. But it also may be personal needs and goals for safety, personal needs and goals in life. They have difficulty interpreting social cues and observing appropriate boundaries with others often thinking that those communications are more intimate than they really are. We want to help them recognize when it's appropriate to hug somebody, when it's appropriate to get close to someone. They have difficulty attending and not disrupting group activities because in large part of their impulsivity, but in group activities, especially if the group is going faster than they can process, it can be very frustrating. So they may start getting antsy and irritable and which will promote impulsivity, blurting disruption. They have difficulty processing information readily or accurately. If you're telling somebody something and they seem to be getting it and then you figure out that they didn't have a clue what you were saying, it's like you said you understood, but then when you tried to do was like you didn't even hear me. It could be that they have ADHD and they just kind of zoned out. It could be that they just didn't understand and instead of causing problems, instead of risking rejection, they just kept nodding and saying, yeah, I got it, not a problem, I know what to do. And then they left and they're like, oh crap. And they may have difficulty acting one's age. Well, I think a lot of us do. But because of their impulsivity and dysregulation issues, which you expect to be significantly improved, if you will, at 18 or 20 versus 6 or 8. We need to help them recognize what is appropriate in different settings when indicators occur in any of these domains. Particularly when there are indicators across multiple domains. Receptive language, expressive language, reading comprehension, math and timekeeping. Impulsivity. You know that, that whole list we went through. If there are issues in multiple domains, consider applying the FASD four Digit Code Caregiver Interview Checklist. And that's a mouthful. It's a good screening instrument. Even with compensatory strategies, the person with an FASD may be less able to use judgment, recognize consequences or understand abstract situations. We want to make sure that they feel comfortable. If they're going into. You say, okay, we're going to go to church. The most abstract I can think of right now. And they hadn't been to church before. In general, you know, they may, they may have difficulty understanding what is expected from them in this situation. They've never been in. It's kind of abstract, not sure how I'm supposed to act, how I'm supposed to react. I mean Baptist churches, Catholic churches, Protestant church, they all have different ways of acting and different things that they do during this, the ceremonies. So it can feel very overwhelming. Social isolation and loneliness may drive the person to seek out any type of friendship which can lead to victimization because bad actors are very often super attuned to those who are vulnerable and easily manipulated. And again, impulsivity is an ongoing issue we need to examine for the person. Is it impulsivity in actions? I think something and I do it. Is it impulsivity in words? I think something and I blurt, or all of the above? So what do we do? Make it safe. That's ultimately what we're going to talk about. Use short, simple instructions and clear language, avoiding complex sentences and jargon. I need you to take out the garbage now. Take the garbage out to the curb now. You know, simple direct communication. If you have more than one thing you want them to do, either write it down, like have a checklist available or give it to them one at a time. Especially for younger people. Maintain eye contact and gain the person's attention before speaking. Whether the person is distractible because of ADHD or they have hyper focus and they're just their brain is still on whatever they were doing two minutes ago. You need to get their attention. Eye contact can help. And for some, it may be. For some that are further along on the spectrum, you may have to make eye contact and say, okay, are you ready to hear what I'm going to ask you? And have them acknowledge you. You ask them to do something, have them repeat it back to you. Now obviously that's for somebody who is way further down the spectrum. It's not for your people with what we'll call mild fetal alcohol injury. Break tasks or instructions. Instructions into single steps, allowing time to process each one before moving on. Think about math class, doing long division. This is the first step. Step. I've got to process it. Okay, let me do the first step. Okay, I did that. Now what's the next step? Let me think about what that next step might be. Okay, let's do that next step. So it's important to slow down and take it step by step and make sure they understand when appropriate, the whys for each thing. What is it that I need to do first? Why am I doing this? What is it that I need to do next? Why am I doing that? Repeat key information and check for understanding by asking the person to repeat or show what is meant. Use visual supports like pictures, charts, objects or demonstrations when talking to them. So if you're explaining to them how to iron a shirt, then you are going to use pictures. You know, you may have a pictograph of what you need to do. You get the iron out, you plug the iron in, you set up the ironing board, you be careful because the iron's hot, you know, have a hot thing on there. And then you show them, you know, this is what we need to do to iron and to avoid burning there. There's actually a lot more to ironing than you would think. But anytime you can show them, tell them, show them and then have them do it. Walk them through it and say, okay, now I'm gonna let you iron the next shirt. So what do you do first? And have them walk through it can be very helpful. If you are working with somebody at a job, you may have to do the same thing. Maybe they are a, a line cook and you need them to do specific tasks. Show them the task, then have them do the task and then back off. So instead of providing scaffolding where you're nudging them along, once you feel like they can do it, back off and observe and watch them do it. Remember, tomorrow they may come in and they may not be able to remember how to do it. They may, you may have to go through that iteration multiple times before it actually truly clicks. Limit distractions to help with focus and processing, especially for those who have concurrent adhd. Limiting superfluous distractions. You know, get the, the dogs and the cats and whatever else out of the room or their little brothers or and sisters or whatever before you start trying to go through something. Use written information such as agendas, step by step guides or checklists and ensure visibility. If there is a routine, maybe in treatment, you have a schedule, you have to be up and showered by 7, you have to be in the dining hall by 7:30, you have to blah, blah, blah, blah, blah. Post that on their door, on their wall, in their room, in. If they're in prison, post it in their cell so they know what is happening and when. And that helps them feel more secure, more empowered because they know what's coming next or what should be coming next. Keep vigilant for situations where victimization is possible. Whether it is from friends, from siblings, from foster siblings, from other people in the treatment center, from other kids at school, from other inmates, whatever. There are almost always bad actors in every group. You know, it happens. We need to be vigilant for those situations because the person with an FASD may not pick up on the nefarious motives, role play, personal safety, and specific scenarios that people face, like identifying who's a stranger versus who's a friend and allow the person to practice that. When you go to the grocery store, you know who's a stranger, who's a Friend who's okay to talk to, who do you probably want to steer clear of? Videotape the person doing it right in the role play so they can watch it repeatedly, which reinforces the lesson. Provide a buddy system. All of these places, with the exception of home. Hopefully you're the buddy if you're the caregiver, but in foster care, treatment, school, jail, if they have a buddy that can help them get through the day, that can help them be wary of what's going on, that can be very liberating in a lot of ways because they have somebody who they can connect with, they have somebody who they can communicate with, who kind of understands what's going on for and with them. And they've got somebody who is going to kind of look out for them. Be be a big brother. Help the person find a healthy structured environment to help them avoid unwanted behaviors. If they are bored, if they are lonely. There's a variety of different issues that may lead somebody to engaging in unwanted behaviors. So what can you do when you are not doing XYZ task? What would be helpful? What would be healthy for you to do? Help the person adjust to a structured program or environment and develop trust in the caregivers or staff. If this child is being put in a new foster placement for the 13th time. You know, every new foster placement there's an adjustment period. If the child is going to a new grade, they have to learn the new teachers, the new routines, the new rules. Make sure that the person is given time to develop trust in the caregivers and staff. In schools it can be really helpful for the youth to meet the teachers ahead of time and have a sit down with the teachers so they feel comfortable and they they're not walking in to meet this strange person on the first day of school. Individuals with FASD tend to be trusting. They need a great deal of structure and may have trouble adapting to changes in routine or new people. If you are going to be out, maybe you're going to be out on vacation and there's going to be somebody else caring for them. Make sure to ease that transition and not just have a new person show up because that'll could throw them for a loop because they're like you're a stranger. I don't know who you are. Don't know what to do here. Share the rules early and often. Sometimes that means repeating the rules at the beginning of every group or at the beginning of every day, checking in with the person. Maybe you're on a pod in the correction facility. Of a bunch of people who have FASDs. And so you begin the day with a group where you go over the rules and just reinforce that. Put instructions in writing and remind the person often where the instructions are. You know, you can remind them verbally, but also make sure to remind them where the instructions are so they can go and they can take their time. Keep rules simple and avoid punitive measures that most individuals with an FASD will not process. If you, if the person with an FASD does something you don't like and you scream at them, they're going to be like what they may not process the cause effect and, and so screaming at them is not going to do any good because it's not going to really punish that behavior because they're not connecting. If a rule is broken, help the person strategize ways they can better follow the rule in the future. Impulsivity is a big one for this. Focus on all pieces of the person's life, physical, interpersonal, emotional, cognitive, environmental and even spiritual. Not just the behavioral, substance abuse or mental health issues. Focus on their strength. Focus on empowering them. Focus on finding their superpowers, not just reacting to problems. Empower them with basic living and social skills and help the person develop appropriate goals within the context of their interests and abilities. Every person is different and finding what is meaningful for any individual is huge. It doesn't matter if they've got an FASD or not. That's huge for any person. Provide opportunities to role play or practice appropriate social behaviors in areas like impulse control, dealing with difficult situations like being teased, problem solving and activities of daily living. For example, eating in a cafeteria. What is it you're supposed to do when you get your tray and you sit down at the table? And how are you supposed to act in these, in these situations? How are you supposed to act if people are distracting you, if people are bothering you, if they're getting on your last nerve? Assume the presence of co occurring issues. Include the person in any sort of treatment planning or modification. And this is, I would call it life planning because a person with an FASD is likely going to have a plan to help them move toward their rich and meaningful life. We want to include them in that. We don't want to coordinate their life for them. We want to help them coordinate their life. Build family, caregiver and caseworker meetings into the plan with a clear agenda. In schools, in treatment centers, in corrections facilities, having a caseworker involved can be huge in relieving some of the burden off of the teachers off of the corrections officers, off of the people who weren't trained for this. So they can understand what better what's going on with Jim Bob as opposed to in general, what's going on in the pod or in the classroom? What is going on with this person right now? Why are they decompensating or why are they withdrawing? We must recognize, especially if we're working with the families, that many family members may also have FASDs. Why is that not connecting the behavior to the consequence? A lot of birth mothers who have FASDs may not connect even though they hear the words, you shouldn't drink when you're pregnant. They may not connect that they may still drink when they're pregnant even if they connect that the lack of impulse control in some ways may put them at higher risk of consuming alcohol while pregnant. So we do want to recognize that, okay, so there is a greater preponderance of if you have a child with an fasd, there's a good chance not, you know, I can't give you exact numbers, but there's a good chance that their caregiver, their birth mother may have also had an FASD and impulsively consumed alcohol. All right, why do we need to care? Well, because the person who, the caregiver, if they also have an fasd, guess what, they're not going to respond well to complex instructions. They're going to have difficulty implementing a multi step treatment plan. They are going potentially going to be able to talk like they understand what's going on, but they're not really understanding much of what you say. So you see how this can get challenging when not only do you have a child with an fasd, but you also have a caregiver whose receptive language and reading comprehension is very low. We need to plan for that. We need to be aware of that and figure out, okay, if that's the case, how do we approach it? How do we structure our interventions with this family to make sure that the caregiver is able to meet the needs of the child? Incorporate multiple approaches to learning such as auditory, visual and tactile. Have them read about it, talk them through it, and have them actually do it themselves. Use multi sensory strategies like drawing, painting or music to assist in expression of thoughts and feelings and take advantage of skills that these individuals have. FASDs often impact the left hemisphere regions and specific temporal and frontal language areas. But a lot of those creative areas, not so much. So, okay, let's help the person figure out how to express themselves this way. Consider sensory issues like light, smell, and sound. Individuals with FASDs can be very sensitive to any of those stimuli, or in some cases, hyposensitive. Not sensitive enough so they may touch something hot and it doesn't even register because they don't perceive it as hot. Sensory processing disorder results from inefficient integration of sensory signals leading to exaggerated or diminished responses to stimuli and is often present in fasd. So we want to recognize this. Not only may they. May they respond differently to lights, smells, and sounds, sometimes they may feel like they can't feel themselves in space. Their proprioceptive abilities are off. They feel like they're floating or something. And working with an occupational therapist and a physical therapist can be helpful at providing tools to help the person integrate their senses, what they're feeling, from what's actually going on. Set appropriate boundaries with your clients or your subordinates who may have an FASD because of social communication problems. They may breach boundaries by making inappropriate comments, asking inappropriate questions, or touching the counselor or caregiver inappropriately. It's often not meant maliciously at all. They just don't understand why it's inappropriate. Have the person walk through the rules and expectations and demonstrate expected behavior, especially before introducing them to new situations. In terms of memory issues, people with FASDs may be able to repeat rules, but not truly understand them or be able to operationalize them. I understand I'm not supposed to hit. Okay, That's. That's one of the rules. Don't hit. Okay? But I don't really understand what that means, and I don't understand when that applies, you know, so what does it mean not to hit? What is hitting? You know, trying to understand what that word is. I can re. You say don't hit, I won't hit. What does it mean to hit? Limit the number of rules and review them repeatedly and role play different situations in which the person will need to recall the rules. Switching classes, going when, eating, when in public places. There are a lot of different situations. You can also have picture books that have examples of this, like a picture of grandma and pictures of grandma's house. When you go to grandma's house, you don't touch these things and so they recognize it. Use charts and reminders. And again, if you want people to remember things, minimize distractions. Allow the person to get up and walk around. If they start feeling restless, they may start feeling stressed out because they're getting cognitively overloaded or feeling overstimulated or under stimulated. Okay? If they need to get up and walk around. That's fine. Use concrete representations like marking on the floor to show the concept of boundaries. This is the red line. This is where you stop and where I start. Use Legos to represent each person. Water to represent energy. Symbolic charts or alarm reminders for routines that can be super helpful. Those alarms are huge. And again, role play, role play, role play every single situation. You're getting ready to go to the doctor before we go, let's role play that. What's that? What's going to happen? You're getting ready to go grocery shopping. Okay, let's role play that. What are we going to do? What's going to happen? If you are working in a group, make adaptations for the whole group to avoid singling out the person. So if you've got somebody who's mainstreamed but they need particular adaptations, they need you to break this instructions down a little bit more granularly. Do it for the whole group. Instead of teaching in general concepts and then going over and identifying, singling out the person who needs more granular steps and going through it with them because then they're going to feel highlighted. If medication is used, simplify medication schedules and provide support. Find something the person likes and have the person do that regardless of their behavior. Make sure that they are doing things that they like. They may have had a bad day. Okay. You know we learn from that throughout the day. But it's also important not to continue to punish them the rest of the day because they, they're not going to understand why they're not going to get it. Create chill out spaces in each setting and be creative about finding ways for the individual to succeed, establishing achievable short term goals and reconsidering zero tolerance policies. I have zero tolerance for being interrupted in groups. Okay, well if you're working with somebody with an FASD that may be setting them up for failure. So zero tolerance for certain things. Of course, you know, we want to keep it safe but recognizing improvements is really what we want to work on. Be consistent in appointment days and times considering shorter, more frequent meetings, classes or appointments. And arrange for someone to get the person to their destination or their classroom or, or their appointment or whatever for at least the first six months. After that they may be able to remember that Every Tuesday at 9 o' clock they're supposed to do this. Use open meeting times if necessary. This, that rarely works for most of yalls schedules. So just having basically a drop in that. All right on Thursday you need to show up. That's probably not going to work for your schedule, but it's a suggestion and Send text reminders with permission. Have pictures of the counselors and staff on their office doors and badges because the person with the FASD is going to be better at remembering faces than names. Identify buddies to ensure the person gets to appointments and meals. Identify persons who are not helpful and help the per Help the person with the FASD remember who those are. Program important numbers and reminders into their cell phone and put a master chart on their wall. Assess comprehension on an ongoing basis and ask the person to summer Summarize what you've said, but also do it, because remember they can summarize a lot. They can say, you just said to do this, this, and this, all right? Do you know what that means? And review important materials such as rules at each session. Don't assume that a person is familiar with a concept or can apply it simply because you've reviewed it multiple times or because they say they can. Make sure that they actually can't have them role play it. Have discussions that explore their understanding and avoid using metaphors, similes, idiomatic expressions, proverbs, or sarcasm because they're not going to get it. Highlight the person's strengths A common theme that caregivers need to be attentive to is their feeling of vulnerability and powerlessness. This can be reflected in the person undervaluing their own competencies, viewing others needs and goals as more important than their own inability to obtain nurturance and support for themselves because they're having difficulty communicating what they need in a way that other people understand feelings of depression, anger and frustration about their lives and what's going on, and low expectations for their own success. Women with FASDs may fear becoming like their mothers, so we may have to process this transference issue with them. People with an FASD also may struggle with forgiveness of their birth mother in and have to work through that in treatment. Reassure people that they are not responsible for their disability and that there are strategies to help them move toward a rich and meaningful life while educating them about the science of their condition. Expect to repeat things many times in many ways. Encourage the use of a written journal or goal sheets and realize that there is no one set approach not only between people. You know each person is unique, but what may work for Jim Bob in January may not work in March, so we need to be flexible and fluid. Millions of people in the US are on the fetal alcohol spectrum and many of them are in your schools and workplaces. You just don't know it because They've learned to adapt. It's especially important to screen those with ADHD diagnoses and those with a history of being in foster care for undiagnosed FASDs, which may significantly alter their treatment or management protocol. Jails, addiction and mental health treatment facilities all have a much higher prevalence of people with FASDs. Other fabulous resources you can look into are the two that are linked here. One is called Addressing FASDs. That's a SAMSA publication and there's also an FASD network that has a ton of stuff. But the particular document I link to is a very succinct summary that can be useful for teachers and caregivers. Alrighty. I know I ran over a little bit. I apologize for that. But thank you for being here and being patient. What questions do you have? Well, thank you, James. There are a lot of people who may have a sibling with an FASD and they don't and they may not understand what's going on. The fact that you tried to make him feel included. The fact that you tried to make him feel belonged, like he belonged what is wonderful. And people with FASDs have the same feelings and the same needs for safety, love and belonging that all of us have. It's just a matter of instead of criticizing and judging, we step back. Not saying that you did, but in general that people step back and go, I wonder why little Tommy is acting that way. Or I wonder why little Tommy is seems to be just completely unable to not be disruptive. What's going on there. And get curious, get curious about what's going on. And it's never too late. People with FASDs that I've worked with in treatment that are in their 30s and 40s undiagnosed because they didn't have those, quote, obvious facial features, they went undiagnosed and or maybe just diagnosed with adhd. But as we work together, this was mainly back when I was working in residential, we were able to develop other compensatory strategies to help them manage the issues that were causing them problems and work toward what was important in their life. And again, looking at it from the perspective of superpowers, how does, how is this a strength that you can use to live your, your highest quality of life? All righty everybody. Have a wonderful rest of your week. I hope it is beautiful this weekend, wherever you are. And I will see you next Wednesday. Oh, we do have a live workshop on working with older adults. It's a six hour workshop on Friday. You can go to allce.comagingwell if you're interested in attending that workshop. If you can't attend the live, you know, I get it. Short notice. I will be publishing the videos from that workshop over the next couple of weeks. So anyhow, have a great day. Take care everybody. I will see you next week.