# Presentation: 111811

## Mental Health Treatment Strategies That Work

**Building FASD State Systems Meeting**
**San Francisco, CA**
**May 10, 2006**** **
**Therese Grant, Ph.D.****  **
**University of Washington Fetal Alcohol and Drug Unit**
**Parent-Child Assistance Program (PCAP)**
**180 Nickerson, Suite #309**
**Seattle, Washington 98109            (206)543-7155**

## Limited research available on effective FASD interventions

**Premji et al., (2004) reviewed the literature on FASD interventions with youth:**
**10 studies found; of 7 reviewed ... **
**2 medication trials**
**1 cognitive control study**
**1 supplementary reading program**
**1 tutoring program**
**1 functional analysis study**
**1 multisystems collaborative community based intervention**

## With no mental health intervention studies to draw on... What to Do?

**Look to **
**Clinical data from professionals, teachers, and parents who have seen positive changes using an intervention.**
**Practices shown to be effective with other** **disorders that are being adapted for those with FASD (e.g., ADD).**

## There’s no cookbook solution for FASD intervention

**“****One-size *****doesn’t *****fit all”**
**- Each individual has a different neuropsychological profile (depending on timing and dosage of prenatal alcohol exposure).**
** **
**- Variability is the hallmark of FASD (within individuals AND between individuals).**

## A source of FASD mental health problems: organic brain damage associated with prenatal alcohol exposure

**The primary disability of FASD is permanent brain damage, manifest as *****neuro*****psychological deficits and *****neuro*****behavioral problems.**

## Slide 6

## FASD = Neurobehavioral Disability  

**Neuropsychological deficits do not go away.**
**They impact the individual’s ability to participate in interventions because of problems with:**
** ****Executive functioning **
**	****(sequencing of behavior, cognitive flexibility, response ****	**** inhibition, planning, organization of behavior)**
** ****Attention**
** ****Memory**
** ****Hypersensitivity to sensory stimulation **
** ****Impulsivity**
** ****Receptive language**

## Strategy: Direct Therapeutic Intervention

**Treat **_**primary**_** mental health problems (e.g., depression, anxiety disorder) with interventions adapted to the individual’s neuropsychological and health profile. **

## Strategy: Direct Therapeutic Intervention 

**PRINCIPLES:**
**Accommodation vs. Cure: **Can’t “cure” the existing brain damage
**Change the environment, not the person **(physical environment, attitudes)
**Individualize:  **Base intervention on the person’s unique neuropsychological and health profile
**Adapt interventions:  **Alter existing interventions based on  individual’s learning style, memory problems, attention deficits, etc.
**Maintain intervention: **Consistency
**Involve others**

## A Second Source of Mental Health Problems:

**Distress caused when a person with FASD ****	****does not receive appropriate support to ****	****address their neurobehavioral deficits, ****	****leading to chronic failure, loss, ****	****frustration, victimization (“secondary” ****	****mental health problems).**

## Strategy: Comprehensive Prevention Intervention

**Provide sustained, comprehensive, multi-systemic and developmentally appropriate support to the individual with FASD. **

## Strategy: Comprehensive Prevention Intervention

**PRINCIPLES:**
** ****Multi-systemic**** (**medical care; mental health; school; 	social service; vocational training agency; social 	services; family; church**) **
** ****Multi-modal ****(**individual therapy; family therapy; 	medication; vocational training/job coaching; case 	management; support groups**)**
** ****Individualized ****(**based on comprehensive assessment**) **
** ****Life-span perspective**** (**sustain the support)
** ****Family-based**** **(involve caregivers/advocates)

## Mental Health

**Psychotherapy focusing on concrete issues (e.g., anger management; social skills; coping with depression)**
**Therapy should also address the emotional pain of being different, having a disability**
**Refer to support groups for individuals with FASD and their families **
**Refer for family therapy **
**Respite care for family members to prevent burnout and development of stress-related health problems**

## Mental Health 

**Traditional talk therapy is not helpful due to the language, memory, and attention problems typical of individuals with FASD**
**BUT, psychotherapy, adapted to the individual’s learning style (i.e., multi-sensory vs. only auditory-verbal; role playing; use of art) can be very beneficial **
**Requires creativity, persistence, clinical intuition on the part of the therapist**
**Involve patient in the process (learning style; cultural sensitivity)**

## Mental Health

**Carefully monitor suicidal ideation**
**Individuals with FASD @ risk for suicide**
**Considerable overlap between the risk factors for suicide and the clinical profile of FASD (e.g., impulsivity; co-occurring mood disorder; substance abuse problems)**
**Also vulnerable due to: job loss, relational loss, social isolation **

## Mental Health 

**Psychiatric medication**
**Medication management is complex: **
***organic brain damage (structural and/or neurochemical)***
***alcohol-related birth defects (e.g., liver) affect metabolism of medication***
***presence of multiple co-morbid conditions***** **
**Risk: overmedication & negative side effects**
**Benefit: control symptoms & allow individual to participate in interventions **

## Social Relationships	

**Arrange recreational activities that provide safe social contacts and friendships**
**Provide ongoing education regarding appropriate sexual behavior and how to protect against victimization**
**Monitor social relationships and use of leisure time**
**Teach friendship skills**

## Financial

**Guardianship of funds may be required or a protective payee**
**Individual should be raised with the idea that he/she will need help managing money**
**Monitoring finances to ensure individual is living within means and not being financially victimized**

## Vocational 

**Specialized job training **
**Sheltered employment **
**Long-term job coaching/training **
**Special focus on social aspects of work (getting along with co-workers; inappropriate vs. appropriate behavior at work)**

## Physical Health 

**Regular primary health care**
**Specialty care if there are ARBDs affecting kidney, liver or heart**
**Ongoing education regarding appropriate family planning**
**Focus on the more reliable methods of family planning (e.g., IUD)**

## Housing 	

**Residential placement may be necessary**
**In-home support for those able to live independently**
**Ongoing supervision and monitoring to ensure safety  **

## FASCETS Oregon: Fetal Alcohol Project

**Three-year study examining the efficacy  of interventions that addressed the neurocognitive issues of FASD **
**Trained multidisciplinary/multi-systemic teams who worked with children/adolescents (ages 3-14) **
**Pretest-posttest results (N=19): **
**Reduced irritability, disruptiveness, anger, aggression, and depression in the children and adolescents **
**Reduced levels of stress in adult caregivers **
**Improved self-efficacy in parents and professionals                  ****	****	****	****	****(Malbin, 2006) **

## Diane Malbin
FASCETS (Fetal Alcohol Syndrome Consultation Education and Training Services, Inc.)

	P.O. Box 83175 
	Portland, Oregon  97283
	Phone/Fax:  503-621-1271

	www.fascets.org
	dmalbin@fascets.org

**FASCETS (Fetal Alcohol Syndrome Consultation Education and Training Services, Inc.)**
**	**
**	****P.O. Box 83175 **
**	****Portland, Oregon  97283**
**	****Phone/Fax:  503-621-1271**
**	****www.fascets.org**
**	****dmalbin@fascets.org**
** **

## Parent Child Assistance Program: Double Jeopardy Project

_**PCAP**_**: An intensive, 3-year advocacy/case management intervention serving high-risk alcohol and/or drug abusing mothers****.**
_**Double Jeopardy**_**: One-year project funded by the March of Dimes to assist women in PCAP with ****FASD and ****develop a community service training model**
**	****	****	****	****Grant, T., Huggins, J., Connor, P., & Streissguth, A. (2005)**
**	****Grant, T., Huggins, J., Connor, P., Pedersen, J., Whitney, N., & Streissguth, A. (2004)**

## Components of PCAP Relevant for Individuals with FASD 

** ****Each mother paired with an advocate for 3 years**
** ****Advocate develops and coordinates a network of ****	****contacts with family, friends, and providers**
** ****Advocate links client with appropriate community ****	****services and/or providers and coordinates this ****	****service network**** **
** ****Individualized service plan **
** ****Advocates also provide advocacy for other family ****	****members as needed**

## Psychosocial Profile: PCAP FASD Clients (N=19)

**Average age = 22 Years (Range = 14-36)**
**Mostly white (60%), unmarried (85%), and poorly ****	****educated (45%)**
**Troubled life history profile**
**	**** ****• ****Family history drug/alcohol abuse (100%)**
**	**** • ****Sexual abuse (79%)**
**	**** • ****Physical abuse (84%)**
**	**** • ****Unstable and disrupted care giving (100%)**
**High levels of psychiatric distress and behavioral ****	****problems**
**Poor quality of life relative to other at-risk populations**

## Advocates’ Experience:“She just doesn’t get it!”

** ****The impact of neuropsychological deficits ****	****was obvious.**
** ****Advocates had to modify their usual ****	****approaches.**
** ****Clients were often unable to learn new ****	****skills or learned them very slowly.**

## Role of Advocate

** ****Implemented an intervention plan ****	****	****	****appropriate for an FASD client**
** ****Helped providers understand the ****	****relationship between organic brain ****	****damage and the FASD client’s ****	****behavior **
** ****Reinforced use of clinical management ****	****	****strategies**

## Strategies When TreatingClients with FASD

**Use short sentences, concrete examples, and avoid analogies **
**Present information using multiple modes**
**Simple step-by-step instructions (written and/or with pictures)**
**Role-playing **
**Ask patient to demonstrate skills (don’t rely solely on verbal responses)**
**Revisit important points during each session**

## Strategies When TreatingIndividuals with FASD

**Teach generalization (don’t assume it will occur) **
**Help client identify physical releases when escalating emotions become overwhelming**
**Be alert for changes/transitions—monitor more carefully, do advance problem-solving**

## "I thought I was weird.  I thought I didn't belong here.  And then when I talked to (PCAP advocate), it was like wow! You know what I’m talking about!” 

			- A PCAP Client with FASD

**	****	****	****- A PCAP Client with FASD**

## Community Service Providers: What We Found

** ****Providers knew very little about FASD.**
** ****Providers had limited direct experience with this ****	****population.**
** ****Few services were suited for individuals with FASD.**
** ****Obtaining a diagnosis in adulthood was difficult.**
** ****Even for experienced PCAP advocates, working ****	****with an FASD client was more difficult than ****	****working with a typical PCAP client.**

## Educating Providers

** ****We identified key providers interested in the problem, ****	****and willing to work with a PCAP client with FASD**
** ****We provided: FASD education, a PCAP case ****	****	****	****manager, and back-up consultation as problems ****	****arose **
** ****Education + hands-on experience = FASD demystified**
** ****Providers learned to deliver services appropriately****	**** ****	****tailored to ****	****specific needs of FASD patients.  **

## 12-month Outcomes

**16/19 were receiving medical &/or mental health care **
**14/19 were abstinent from both drugs and alcohol****	**
**	****(11 maintained abstinence; 3 newly in recovery)**
**5/19 were still using drugs/alcohol but 3 of these 5 were using reliable birth control methods **
**   ****(****2 tubal ligations, 1 Depo Provera).**
**14/19  were using contraception regularly ****	****	**
**     ****(Depo = 7; Tubal = 3; IUD = 2; OCPs  = 2);**
**16/19 obtained stable housing **

## Reflection on Outcomes

**Result: **We connected clients to providers and educated providers about FASD
**Problem:  **People with FASD require coordinated services throughout the lifespan
**Conclusion: **Need a FAS Advocate program (FASA) modeled after PCAP that provides longer-term advocacy to help clients and families navigate complex community systems of care

## Conclusion: Need for FAS Advocate program (FASA) modeled after PCAP that provides longer-term advocacy

**Well-trained advocate assigned to an FASD client and his/her family**
**Link client with community services and  providers**
**Help client and family navigate complex community systems of care**
**Advocate supported by intensive training, supervision, and peer support**