# Presentation: 215079

## FASD and Co-occurring Disorders

- Dan Dubovsky – FASD Specialist
- Building FASD State Systems Meeting
- May 5-6, 2004

## FASD and Other Disorders

- Those with a fetal alcohol spectrum disorder frequently have other disorders
- Some may be co-occurring disorders
- Some may be misdiagnosed
- Accurate diagnosis of all disorders is essential
- A **t****horough** diagnostic work-up must be done
- Medical
- Family history
- Mental health
- Developmental disabilities
- Neuropsychological testing
- Adaptive functioning testing

## Fetal Alcohol Spectrum Disorders As Co-occurring Disorders

- People with mental illness frequently use substances
- Estimates are at least 50% have co-occurring disorders
- The percentage is as high as 70% in corrections
- Many mental illnesses have a genetic component leading to vulnerabilities in offspring
- Substance use disorders may have a genetic component leading to vulnerabilities in offspring
- Therefore, the risk of giving birth to a child with a FASD and vulnerabilities for mental illness and substance use is higher than in the general population

## Fetal Alcohol Spectrum Disorders As Co-occurring Disorders

- It has been shown that stressors can exacerbate underlying disorders
- Individuals with fetal alcohol spectrum disorders experience multiple stressors in their lives
- Therefore, the likelihood that a person with a fetal alcohol spectrum disorder and these underlying vulnerabilities would have a co-occurring mental illness and/or substance use disorder is significant

## Fetal Alcohol Spectrum Disorders As Co-occurring Disorders

- We are aware of multigenerational alcohol use disorders in some families
- The possibility that a person with a mental illness and a co-occurring substance use disorder from such a family would also have a FASD is significant
- The possibility of prenatal exposure needs to be addressed

## Likely Co-occurring Disorders

- Attention-Deficit/Hyperactivity Disorder
- Substance use disorders
- Schizophrenia
- Major depressive disorder
- Bipolar disorder
- Anxiety disorder
- Separation anxiety disorder
- Reactive attachment disorder
- Posttraumatic stress disorder
- Traumatic brain injury
- Conduct or Oppositional Defiant disorder

## Profile of 80 Birth Mothers of Children with FAS(Astley et al 2000)

- 100% had alcohol use histories
- 96% had one to ten mental health disorders
- 77%:	PTSD
- 59%:	Major depressive episode
- 34%:	Generalized anxiety disorder
- 22%:	Manic episode/Bipolar disorder
- 7%:	Schizophrenia
- 95% had been physically or sexually abused during their lifetime
- 79% reported having a birth parent with an alcohol problem

## The Importance of Recognizinga Co-occurring Fetal Alcohol Spectrum Disorder

- Optimal outcomes in the treatment of co-occurring disorders occur when all are accurately diagnosed and treated simultaneously
- If one or more co-occurring disorders is not recognized, treatment will not be “successful”
- Secondary disabilities can result from frustration, failure, misunderstanding of the difficulties, and lack of acceptance from peers, family and others
- These secondary disabilities can increase when co-occurring disorders are not recognized and treated

## The Importance of Recognizinga Co-occurring Fetal Alcohol Spectrum Disorder

- The cognitive impairments in FASD can interfere with the ability to be successful with typical treatment approaches
- Literal thinking
- Inability to respond to point or level systems that require a sense of historical time and future time
- Difficulty with multiple directions
- Difficulty following through with multiple treatment plans
- Difficulty with treatment based on verbal receptive language skills (i.e., most of our treatment modalities)
- Difficulty with treatment based on processing information outside sessions

## The Importance of Recognizinga Co-occurring Fetal Alcohol Spectrum Disorder

- When a fetal alcohol spectrum disorder is not recognized:
- These individuals often fail in our traditional treatment programs
- They say they know what they need to do but don’t follow through
- Many have mental health problems
- Care givers with unrecognized FASD are often labeled as non-compliant, uncooperative, uninvolved, or sabotaging
- They don’t follow through on multiple instructions

## The Possibility of Misdiagnosis

- Since fetal alcohol spectrum disorders are not psychiatric diagnoses, they are often not recognized by mental health professionals
- The symptom presentation of individuals with an FASD is similar to that of a number of psychiatric disorders

## The Possibility of Misdiagnosis

- The possibility of prenatal alcohol exposure causing some of the symptoms is often not considered
- Even if a fetal alcohol spectrum disorder is recognized, another diagnosis may be used in order to provide services and treatment
- At this time, the most accurate place in a mental health (DSM-IV) diagnosis to identify FAS would be on Axis III as it is a medical diagnosis (760.71)

## Likely Misdiagnoses for Individuals with an FASD

- ADHD
- Oppositional Defiant Disorder
- Conduct Disorder
- Intermittent Explosive Disorder
- Major Depressive Disorder
- Especially in adolescents

## Likely Misdiagnoses for Individuals with an FASD

- Bipolar Disorder
- Psychotic disorders
- Autism
- Asperger’s syndrome
- Antisocial Personality Disorder
- Borderline Personality Disorder

## Comparing FASD, ADHD and Oppositional Defiant Disorder

| FASD | ADHD | Oppositional Defiant Disorder |
| --- | --- | --- |
| Do not complete tasks | Do not complete tasks | Do not complete tasks |
| -may or may not take in information
cannot recall information when needed
cannot remember what to do | -takes in information
-can recall information when needed
-get distracted | -takes in information
-can recall information when needed
-choose not to do what they are told |
| Provide one direction at a time | Limit stimuli and provide cues | Provide positive sense of control; limits and consequences |

## Comparing FASD, ADHD and Conduct Disorder

| FASD | ADHD | Conduct Disorder |
| --- | --- | --- |
| May hit others | May hit others | May hit others |
| -someone told them to
-misinterpret intentions of others
-may sense bump as attack
-may respond from history of abuse | -frequently an impulsive act | -plan to hurt others
-misinterpret intentions of others as attack or impending attack |
| Deal with misinterpretations at the time; 1-to-1 support | Behavioral approaches to address impulsivity | Consequences; cognitive behavioral approaches |

## Comparing FASD, ADHD and Conduct Disorder

| FASD | ADHD | Conduct Disorder |
| --- | --- | --- |
| Take risks | Take risks | Take risks |
| -do not perceive danger | -act impulsively | -push the envelope; feel omnipotent |
| Provide mentor; utilize a lot of repeated role playing | Utilize behavioral approaches (e.g., stop and count to 10) | Psychotherapy to address issues; protect from harm |

## Risks of Not Recognizing and Appropriately Treating an FASD

- Inaccurate diagnosis
- Mislabeling
- Inappropriate treatment
- Unemployment
- Psychiatric hospitalization
- Loss of family
- Homelessness
- Jail
- Death
- Suicide, accident, murder, untreated physical illness

## Benefits of Identification and Diagnosis of an FASD

- The individual is recognized as having a disability
- May decrease anger and frustration on the part of the individual, the family, providers, and the community
- The individual may feel relieved that s/he is not just “lazy” or “a bad person”
- We can focus on why the person is not succeeding in a program and how we can help them succeed
- Address the need to define “success” for each individual

**Notes:**
Secondary disabilities emerge from experiences of frustration, failures, and lack of acceptance from peers and adults.  

## Benefits of Identification and Diagnosis of an FASD

- If we recognize an FASD, we can improve treatment outcomes
- Those at highest risk of giving birth to a child with a fetal alcohol spectrum disorder are women who have already given birth to a child with a fetal alcohol spectrum disorder
- Therefore, an essential prevention approach is the recognition of, and ***successful*** treatment for, these women
- Some of them may have a fetal alcohol spectrum disorder
- Fetal alcohol spectrum disorders are 100% preventable

**Notes:**
Secondary disabilities emerge from experiences of frustration, failures, and lack of acceptance from peers and adults.