Mental Health Treatment Strategies That Work - PowerPoint PPT Presentation

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

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

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).

“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).

The primary disability of FASD is permanent brain damage, manifest as neuropsychological deficits and neurobehavioral problems.

• 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

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

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

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).

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

• 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)

• 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

• 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)

• 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

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

• 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

• 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

• 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)

• 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)

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

• 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)

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

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)

• 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

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

• 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.

• 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

• 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

• 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

- A PCAP Client with FASD

• 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.

• 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.

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

• 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

• 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