Mental Health Treatment Strategies That Work

1. 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

2. 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

3. 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 otherdisorders that are being adapted for those with FASD (e.g., ADD).

4. 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).

5. 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 neuropsychological deficits and neurobehavioral problems.

7. 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

8. 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.

9. 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

10. 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).

11. Strategy: Comprehensive Prevention Intervention Provide sustained, comprehensive, multi-systemic and developmentally appropriate support to the individual with FASD.

12. 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)

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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)

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

22. 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)

23. 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

24. 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)

25. 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

26. 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

27. 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.

28. 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

29. Strategies When TreatingClients 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

30. Strategies When TreatingIndividuals 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

31. "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

32. 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.

33. 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.

34. 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

35. 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

36. 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