 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on fetal alcohol spectrum disorders. Today we're really going to be talking about FASD in terms of people that are involved in the mental health and criminal justice systems. A lot more on mental health, criminal justice will be more on part two, but we're going to kind of talk a little bit about both. So where to begin? There is so much stuff we can cover on FASD because I find that there are a lot of people, whether you're working in child welfare, mental health or criminal justice, that are really unaware of fetal alcohol spectrum disorders and exactly what it means and what impairments people with FASDs may have and all kinds of stuff. And a lot of times it makes it more difficult for us as professionals to understand why clients are doing what they're doing if we don't understand their diagnosis and don't understand their capabilities. And once you understand what a person with FAS or FASD may or may not be able to do, then it puts their behaviors in a completely different light in many cases. And I will state repeatedly throughout the presentation that while being oppositional and not following rules can or appear and not following rules, can be a characteristic of someone with an FASD. It also can be a characteristic of a whole bunch of other stuff. So we don't want to just assume that someone's behaviors are because of an FASD. But if we see a certain set of behaviors, we do want to explore to see if they don't have the tools or the abilities to follow certain directions or if they need certain modifications. So we're going to explore the scope of the problem. The first couple of slides are really mundane and I do not test you on percentages and all that kind of stuff, but I want you to realize how important this is. Then we'll identify the impacts of the impairments across domains and discuss specific issues for adolescents and in treatment centers. I learned a lot when I was doing this presentation about modifications we really need to make, not only in the treatment center, but also with suicide interventions with clients who have an FASD. So the National Institute on Alcohol Abuse and Alcoholism says the prevalence of FAS, which is the worst level on the spectrum, so to speak, in the general population ranges from 2% to 5% for the entire continuum, but FAS is out there and it's more like two out of every thousand. So whatever that works out for percentages like 0.2%. But that's still, even if you've got 5% or let's say 2% of people in the general population that have some level of an FASD, that means two out of every 100 school kids. Well, if you've got 20 kids in a room, that means in five rooms, there are going to be at least two children that have an FASD. So there are going to be at least two children who have some need for special modifications. 94% of individuals with an FASD also have a mental illness. And 73% to 80% of children with full-blown FAS are in foster or adoptive placement. So let that sink in for a second. So our foster care system and our adoption system as well as our mental health system has a much higher proportion or percentage than the general population of FAS. 61% of adolescents with an FASD experience significant school disruptions. They had difficulty following the rules. They had difficulty functioning in that environment. And we're going to learn more why as we get into the presentation. Now this one I found just absolutely stunning. The prevalence of FASD in the child welfare system is 17 to 19 times higher than the general population in North America. According to a meta analysis published in the Journal of Pediatrics. Wow. So almost 20 times higher than in the general population is if it's two to 5% in the general population, that means we're talking almost 40% to, you know, my math is not that good. A lot of kids that are in the child welfare system are struggling with an FASD. 12.8 is the average age children with an FASD become involved with the law. And overall, when we're looking across their lifespan, 60% of people with an FASD end up having a history of trouble with the law. So again, why is that? Are they malicious? No. Are they, what is it that's causing them to have problems with the law? And well, I'll get there later. FASD, and you may be going, well, what are we talking about here? It's not a diagnostic term, but an umbrella term encompassing four categorically distinct diagnostic entities. Fetal alcohol syndrome, which is the worst, if you will, on the continuum. Partial fetal alcohol syndrome. Alcohol related neurodevelopmental disorder and alcohol related birth defects. One of the things we don't know is, you know, what exactly is going to be amiss in children at each different level, because we don't know where or when the negative impact happened during the fetuses development. So just because somebody has an ARND as opposed to FAS, you know, they may have some pretty significant impairments. They just don't have all of them, but we don't know what those impairments are going to be. So it's kind of like three out of five instead of five out of five. All right. So what we want to look at is what are the problems? Well, these people with an FASD have problems in multiple domains which interfere with treatment and life success. Some of these problems, they have difficulty remembering program rules or following multiple instructions. So thinking of adolescents you've worked with or of adults you've worked with, you know, if you tell them the rules, and they just repeatedly seem to break them and you remind them of the rules and they keep breaking them. You might want to wonder, are they breaking them intentionally or can they not remember them? Can they not process them? They may be able to remember them and tell you exactly what the rule is, but not really understand what it means. It's kind of like when the analogy I can give you is when I tell my kids to clean their room. And it's important for them to keep their room clean in order to get certain privileges. And they can tell me that rule. Now what exactly does a clean room mean? What exactly does it mean to clean their room? And that's not exactly on point, but it gives you a little bit of an idea about how what may be going on or what you may be hearing as a clinician or as an administrator where somebody's spitting the rules back to you, but they're not able to operationalize them. And following multiple instructions when children are younger, especially, and people with an FASD tend to have a younger developmental level cognitively than their actual physical age. But think back to your children. I remember when mine were young, they couldn't follow multiple directions. You'd be like, okay, you need to do this. And then you need to do that. And then you need to do the other thing. But if you told them, I need you to do this, that and the other thing, they would hear this. And that and the other thing would go out the other ear. So we need to make modifications to help them follow multiple instructions. And a lot of the children or people with NFASD can be misdiagnosed as having autism. So we want to look at exactly where the functional impairments are. And there is some overlap, but we'll look a little bit more at that as we go. They have difficulty remembering and keeping appointments or they may get lost on the way there. They have difficulty independently making appropriate decisions about treatment or life needs and goals. What is it that I need to do in order to get a job? What is it that I need to do in order to recover? And they can't put together a treatment plan. They can't put together a cause and effect, especially of chained behaviors. You know, sometimes they can see if I do this right now, I will get this. And we're going to talk about difficulty with understanding cause and effect in a few minutes. They have difficulty appropriately interpreting social cues, which can lead to a lot of inappropriate sexual behavior and sometimes some inappropriate aggressive behavior. They have difficulty observing boundaries with staff and other clients. And a lot of this is because they have underdeveloped social skills and they have difficulty understanding and interpreting social cues, especially nonverbal ones. So this is a huge area that we need to help clients with, especially if we're talking, you know, I come from a residential treatment setting. From my perspective and working with clients in that setting, making sure that they are not misinterpreting the nonverbal communication from staff or other clients and setting themself up for a situation in which they could be victimized or end up feeling threatened and acting out. They have difficulty attending to and not disrupting group activities. They're not processing information as quickly and accurately as everybody else. This is also a group that you tell them to act their age. They can't because they may be physically 16, but cognitively they may be 11. We need to understand from that perspective, what age are we asking them to act, we need to understand what age they are developmentally, not necessarily physically because that's kind of where we're going to be focusing. When any of these indicators occur, particularly if they occur across multiple domains or if there's multiple indicators, it's worthwhile to apply the FASD four digit code caregiver interview checklist. And the Astley 2004 there's the link there so you can go ahead and click on that and go to the FASD four digit code caregiver interview checklist. You can use that now a diagnosis of an FAS of FAS or an FASD requires a multi disciplinary team. A lot of testing there's a whole bunch of stuff that goes into it it's not something we're going to diagnose in a mental health clinicians office in an hour. But it's important for us to screen for it so we can say this might be going on, and we can refer out. To the input from the developmental specialist and the neurologist and anybody else who needs to be involved. When we're talking about adolescents. Evidence shows that the adolescents will commonly exhibit learning and behavior challenges. So on top of social challenges and everything they have difficulty getting along from day to day, remembering what to take to school remembering what to put in their backpack. It feels like you are still trying to deal with them like they are in kindergarten. But again, you want to think back, cognitively, what is their cognitive developmental age. They have difficulty remaining organized and regulated. So you're looking at an 18 year old who may have the cognitive development of an 11 year old. What did your kids, how well did your kids remain organized and regulated when they were in late elementary or middle school. So you need to try to put your head in the space of where they are cognitively. They learn information slowly, especially what is said to them. So it's hard for them to hear information process it, interpret it and apply it. Because of that, they tend to forget things. Well, in part, they tend to forget things that they've recently learned because a lot of what we learn is verbal, you know, I'll tell people what the rules are for the program. Yes, they have written instructions, but they also have to read those written instructions and remember them. And there's a whole lot of stuff going on when they're in a brand new program. So that's also confounding what's going on because they're distracted they're trying to get settled. There's a whole bunch of stuff going on. They may make some mistakes over and over. One of the things that I would always look for when I was working with clients is looking at their criminal history. A lot of times clients with an FASD will make have the same charges over and over and over and over again they don't escalate, whereas in a more traditional criminal behavior pattern. You often see an escalation or a diversification into, you know, from sale of drugs to or from possession to sale to something else to, you know, aggravated assault, whatever. But with people with an FASD, you often see they are making the same mistakes. It's like they're, they get caught, but they don't learn from that mistake and they get caught again. So if you see something like that, you might say why is this person not learning from their mistakes or continuing to make the same mistake. They have difficulty with impulsivity finding it hard to inhibit responses. So when they feel like getting up and walking around their propensity is to get up and walk around. As far as social communication, remember I said their social skills were underdeveloped they have difficulty reading nonverbal communications and verbally they have difficulty understanding what the important details are so they can tend to be very, very vague. If you're used to working with clients who have oppositional defiant disorder conduct disorder addictions. Some of these things you might attribute to them trying to be manipulative. So again stepping back and going, is it them being manipulative and intentional, or is it that they can't do any better. And they need some sort of modification to help them out. They're very suggestible and influenced easily by others so in a residential setting, whether it's residential child welfare residential treatment. It's important to be aware of the fact that other children and other staff are in the position where they can be very influential over this person. And if their motives are not good, then they can kind of lead this person into a position where they're making poor choices. Their immature social skills can lead them to be too friendly and trusting and make it difficult for them to recognize dangerous situations. So I want you to think of somebody with FASD as being more gullible, if you will, and easily influenced by others wanting to be befriended and kind of get your head right there with them. There's some evidence for distinguishing between children with FASD and children with ADHD using the four factor model of attention. So I found this really interesting because children with FASD have difficulties with encoding, which means taking in the information, processing it and coming up with something meaningful and shifting attention. They have more of a hyper focus. So if they're on one task, they find it much more difficult to switch to the next activity or switch to the next topic in the discussion. Children with ADHD on the other hand, tend to have problems with focus. They, they, you know, they're kind of all over the place and they have trouble staying on one topic and sustaining their focus. So, you know, it's a really interesting article. Again, I put the hyperlink here for you because if you work with youth or adults who have FAS and or ADHD. This is one area that you can look at for trying to start to differentially diagnose what's going on. So suicide intervention, like I said, it's different for people with an FASD because they have difficulty thinking abstractly. They have difficulty understanding the consequences. So a standard suicide assessment needs to be modified. Instead of saying something like how does the future look to you. We want to ask them something more concrete. What are you going to do tomorrow? Or what do you think about you're going to do tomorrow or next week. Something very tangible, very concrete, very planning oriented. How does the future look, not only talks about the future, but then some abstract concept about what does it look like. So you want to, again, think cognitively, where's the person that are they thinking and abstract, formal operational thought, or are they more concrete operational. Additionally, the seriousness of the suicidal behavior doesn't necessarily equal the level of the intent to die because they may not understand the consequences. They may not understand it's permanent. So if they are using, you know, a knife they're trying to hang themselves are trying to shoot themselves. We don't know whether their intent is actually to die. Because they may not understand that that outcome is is really permanent. You want to obtain family and collateral input regarding exacerbating and mitigating factors whenever possible, because remember the person with an FASD is going to be somewhat vague and their responses to questions not understanding what important details to give you if they even remember them. So it's important to get with family and friends, whoever you can to figure out what may have triggered the situation and what things does this person have to look forward to what hope is there in the future for them. Be careful about using words regarding other suicides or deaths. So what do we do to reduce risk? Because, you know, once they get to that point, obviously we're in crisis stabilization mode. But things we can do with people with FASD to help reduce risk include addressing basic needs and increasing their stability in their living environment. So if they're bouncing around from foster care to foster care, if they're having difficulty adjusting when they first start in a new program, whether it's treatment or educational or whatever, we want to help them feel stable. We want to help them feel welcomed and, you know, like they belong. Address depression issues, which are very common with people with an FASD. They do tend to want to make friends. They do tend to be suggestible. Some things that we, without an FASD would blow off, they hear, and they don't understand. It can be a confusing world for them. So we want to treat the depression. Teach distraction techniques to help them deal with, you know, distress tolerance techniques to help them deal with unpleasant emotions when they occur. They remove lethal means. So if somebody is in a, in a place where they might become suicidal, they don't have easy access because remember people with an FASD tend to be very impulsive. And increase social support, which is easier said than done sometimes. If your staff and or the participants in your program, students or clients or whatever they may be, don't understand this person's behavior. Think about it. If you've got an adult who is in an adult treatment program, but has the cognitive development of, you know, an 11 or 12 year old. So that's how they're kind of interpreting the world. Yet, they can hear rules and they can spit stuff back out, kind of tell you what the rules are, but they may not be able to apply them. So people are like, well, I'm here. I'm seeing you're an adult. I'm hearing you say that you get it, but then you act a completely different way. So I don't understand how all this fits together. And we don't want to single out the person with an FASD and go, All right, everybody, we're going to have a group on how to understand john. It's totally inappropriate, but we do want to help people in the program understand that everyone's different and try to approach it from a more global perspective. When you're working with people with an FASD, don't use suicide contracts. They're useless. I mean, there's a lot of research that out there that shows that in large part suicide contracts aren't really very helpful anyway. People with an FASD have so much impulsivity. The only one it makes feel better is the clinician, and it doesn't do anything to actually prevent the action. Monitor risk closely because of the impulsivity because of difficulties with interpreting nonverbals. The situation can go south really fast. Build reasons for living, being literal. And again, this goes back to anything if you know this person you've already worked with them in your program and getting with family and friends and supports and roommates anybody you can reach out to to identify specific reasons. This person wants to live. Remember, they're more vague and strengthen the advocate-client relationship. So help them understand that you're there for them. You hear how much pain they're in right now. Once you're past that crisis phase, if the person is in a treatment setting, it's important to understand how to make it safe, not only from a risk management standpoint, but from an ethical client standpoint. We all do no harm. We need to make sure that we create an environment that's not going to victimize these clients. So understand that clients with an FASD may be maybe less able to use judgment, consider consequences or understand abstract situations. They need concrete. So if you're working with a staff that has a lot of text, you know, help them again understand, because sometimes abstract versus concrete, they're just like, huh. But help them understand that you really want to make it more like a situation you would do with elementary age children, because that's concrete. I didn't tell them, you know, about things that we're going to do that would make them happy. You might want to talk about specific things like does going to the circus make you happy. Social isolation and loneliness may drive the person to seek out any type of friendship and lead to victimization. They have the poor development of their social skills, their difficulty interpreting nonverbals, they have difficulty making friends. And like everybody, they want friends, but even to a greater extent, it seems people with an FASD tend to want friends. So they may seek out friendship and in a treatment environment that can easily be taken advantage of. And for situations where victimization is possible. So with this particular client in individual session you may need to role play personal safety and specific scenarios that they may face in the in that setting, who is a stranger who's a friend, what they need to do in order to be safe, what happens if they're in this particular situation, you know, at our facility. It would happen where somebody would bring contraband onto the unit. So you want to role play personal safety. What do you do in that situation, videotape the client doing it right in the role play. So he or she can watch it repeatedly reinforcing the lesson. Because remember, even if you talk about it, you rehearse it you role play it. There's a likelihood that they're not going to actually remember that and it's not going to be committed to memory so allow them to continue to watch that videotape. Establish written routines and structured time charts and have these where they're easily seen throughout the day. If you're in a unit where you have a general structure. In our unit we had a wall where the schedule was for the day and the at the end there was also the menu for the for the cafeteria. But you can also have them keep it in their notebook so they can look at it anytime of the day and they know what's supposed to go on. If you have the ability, if you have clients where you can create a buddy system. It may help decrease opportunities for victimization. So the client find a healthy structured environment in after care to help them avoid criminal activity or relapse. So, looking for situations, you know, maybe if they go back to that same situation. They're going to be too vulnerable to relapse because there are people who might take advantage of them. So they may need to go into a recovery residence or a sober home or whatever they call it where you're at. The client adjust to a structured program or environment and develop trust and staff is the first step as soon as they come in. I mean some people adjust better than others individuals with NFASD tend to be trusting, but they need a great deal of structure and tend to have trouble adapting to changes in routine. Remember, I said they have difficulty switching. I don't remember what they called it in the four four factor attention model. If there's a change like normally there's a 1pm group, and all of a sudden there's no 1pm group. It may be really stressful on the person when the routine changes, especially if it's not a permanent change. One of those places where it kind of overlaps with some autism like symptoms. If you think back to Rain Man, when there were certain things that you know, Wapner happened at three, and that was what they were going to do and it was very very distressful or distressing if he couldn't do that particular activity at that time. Put instructions and writing and remind the client often. So again, they don't process verbally as well. You want to remind them, but have them read them. You know, I want you to go back and read your rules of what happens. They can do that every morning before they start group they can review rules before each group. There are certain things and you can cue them, you know, tap them on the shoulder or give them certain cues so you're not singling them out. At the beginning of group you can also go over the rules every single time in order to make sure that everybody in the group is on board. The rule is broken. Remind the client of the situation and help strategize ways they can better follow the rule in the future. And that's starting to get somewhat abstract. So it's going to be difficult to actually implement this with the client is not impossible, but you don't want to assume that the rule is going to be broken, you're going to strategize and you're done with it not going to have any more problems. Probably going to come up again, and you're going to have to go back to saying, okay, your strategy for handling this was to do X, Y, and Z. So either what prevented you from doing that or how can I help you remember to do that the next time. Focus on all aspects of the client's life, not just the substance abuse mental health or criminal justice issues. They are a whole person in order for them to function in society they need to, you know, have the life skills and the interpersonal skills. Help the client develop appropriate goals within the context of his or her interests and abilities. And remember, think vague. I've had clients come to me going I want to be happy. Okay, I don't know what that means for you so let's talk about that. So we can take their vague statement from what their goals are or their interests and abilities. And we can help them kind of narrow it down but it's writing the treatment plan or developing the goals is going to be a lot more incumbent upon us than it necessarily is with clients who do not have an FASD. Provide opportunities to role play or practice appropriate social behaviors. This is a huge thing for people with an FASD. To develop an awareness of who's safe who's not safe prevent victimization and develop enough social skills where they can have a supportive social network in the general population, if you will. Areas of focus may include impulse control dealing with difficult situations such as being teased or somebody disagreeing with them and problem solving. It's important that we assume the presence of co-occurring issues and include the client in treatment planning and modification. Again, some of it's going to be difficult for them to kind of participate in or wrap their head around, but it's important to have them there and discuss it with them so it's not being done for them or to them, but it's being done with them. If there is a appropriate family or caregiver who wants to be involved in treatment, which is ideal, build them into the plan with a clear agenda of what's the goal here. What's the goal for mom and john to get out of our group sessions together. Recognizing that some family members may also have an FASD. It is not unusual for a child with an FASD to have a parent to have a mother who has an FASD. Again, if you can't really think about connecting actions and consequences, it's difficult to connect drinking alcohol when I'm just barely pregnant to having birth defects 10 months later. It's hard to make that connection. So, and there are some impulse control issues and if the person was drinking there may also be some addiction issues. So, understanding that, you know, FASD is seen intergenerationally in many, many families and preparing to deal with that. Incorporate multiple approaches to learning such as auditory visual and tactile. And I say this for everybody, not just for people with an FASD. If you're doing group, talk about it, give them an outline or give them something to read and have them acted out role play it do something where they can apply it and actually kind of manipulate the information in order to make it meaningful to themselves. The guidelines do say to avoid written exercises and focus more on hands on practice role playing and using audio video recording for playback and reinforcement of learning. Now you may not want to, if you do the recording, you may not want to replay it and dissect it if you will in group. If you're videotaping a group and you're videotaping a role play you may want to go over that with that person in individual. But that will also help them see what they're doing well. Use multi sensory strategies to assist in the expression of feelings and take advantage of the skills that clients with an FASD do have and that tends to be more on that creative side of the brain more than the mathematical side of the brain. Not always, but tending to be. Remember sensory issues and this is another easy peasy or relatively easy peasy adjustment we can make light smell and sound. If you have those obnoxious fluorescent lights, you know they're bright enough anyway and it can be distracting and bothersome to certain clients, but if they're flickering. If they're flickering it can just throw somebody completely off. If somebody's got epilepsy it can actually trigger a seizure. So understanding that lighting in the room needs to be consistent. If there are certain strong smells, it may bother the person or distract them and same thing with sounds and it may not be, you know, loud sounds from them buffing the floor in the cafeteria. It may be somebody sitting next to them in group clicking their pen. After a while it gets really old and so many of us are able to filter that out and just be like okay that's annoying not going to pay attention to it. Someone with an FASD may not be able to filter that out. So be especially aware of what types of sensory issues that person may have and they may not know when they first come to treatment. So that may be an issue that you can work on with them about what things in the environment make them more vulnerable to being impulsive to being uncomfortable to having difficulty staying in that environment. Remember that more effort may be needed to convey basic concepts and promote a positive therapeutic relationship and environment. And in the next segment on FASD. I'm going to talk about some clinician survival tools, because it's hard enough with a traditional client to build a positive therapeutic relationship and environment and everything and keep everything going in a positive direction. This particular set of clients has even more difficulty with building this positive therapeutic relationship because it seems sometimes like they're being intentionally oppositional. It seems sometimes like they're intentionally trying to get attention. And I could say a lot more of those it seems sometimes, but their behaviors seem to be counterproductive to the treatment process so we can get really frustrated as clinicians and be like, why is this person not progressing and stepping back and figuring out where that client is cognitively, interpersonally, etc on a developmental scale can help you understand a little bit more but also once the report comes back from the diagnosing team, you'll understand a little bit more about any neurological problems they may have any problems that we know that might cause problems with memory or impulse control or whatever. Set appropriate boundaries when you're working with these clients. And I recommend more so than with other clients having sessions videotaped, not only so the client can see, you know, successes that they're having, but also because it's protective and if your agency disagrees with that if you disagree with that totally get it. But because of social communication problems, some clients with an FASD may breach boundaries by making inappropriate comments, asking inappropriate questions, or touching the counselor inappropriately. So you can see where ethical issues may come up and misinterpretations of the counselor's intentions may also come up so being very, very, very cognizant of the communication and setting and maintaining boundaries. Repeatedly have the client walk through the rules and expectations and demonstrate expected behavior, and it can be very, very confusing in addictions treatment. Because in many 12 step based programs and all the programs I've worked in have been 12 step based so from my experience in those. The clients at the end of certain groups will hold hands will hug, etc. and that's not considered inappropriate. And sometimes the clinicians are involved in that whole group hug and it's not considered inappropriate. So it's very confusing for somebody with an FASD to understand when is it okay to touch. When is it not okay to touch what is a good hug versus a bad hug and it gets really confusing. So ensuring that the clients have guidance as to what to do and maybe looking at modifying program standards, if that's necessary, and that's on a case by case program by program basis. Persons with an FASD frequently expect experience difficulty with memories and may be able to repeat rules but not truly understand or opera operationalize them. So I need to follow my treatment plan. Yes, you do. What does that mean chirping of the different crickets. So keeping things simple, keeping things concrete that means you need to go to group at 9am. That means you need to go to group at 11am and helping the person repeat that until it's ingrained limit the number of rules and review them repeatedly role playing different situations in which the person will need to recall the rules. So if you've got rules and maybe you're going out for an outing, you know role playing that situation before the outing so the client is reminded of what they need to do when they're in that particular situation because they have difficulty translating. When I'm in this situation these behaviors are okay, but when I'm in this situation. These behaviors are okay, but they're not the same behaviors. You act at work versus how you act at home. Be aware of the client's strengths. You know so far I've talked about all of their deficits, but clients with an FASD have tons of strengths. They're compassionate. They are often very creative. So, learn about the client and figure out what's this person bring to the table. A common theme that we need to be attentive to is powerlessness and these clients may undervalue their own competencies because all their life they've heard that they're a troublemaker, or they can't remember or they're dumb or, you know, you can imagine what people would say to someone who has some of the deficits we've talked about. They may view others' needs and goals as more important than their own because, you know, they want to be liked, they want to be appreciated. So when they've complied with others, then they've gotten the reinforcement that they're looking for. So they pay attention to those people and not so much themselves because they're afraid of rejection. And a lot of times it's difficult to get to that point with someone with an FASD getting to that abstract concept of being afraid of rejection, but from a clinical standpoint we can look at what's the motivation. They may have an inability to obtain nurturance and support for themselves. If they're speaking in vague terms, they have difficulty with communication. They are not really understanding nonverbals. They may not know what they need and they may have difficulty communicating, you know, maybe that they just need a hug or maybe they just need to be listened to. And that's a pretty advanced concept. I wouldn't expect, you know, someone who is cognitively at the age of an 11 or 12-year-old to be able to necessarily know exactly what they needed in terms of nurturance and support and effectively ask for it. They may have feelings of depression, anger and frustration about their lives because it seems like they just keep growing up and they have feelings. They're not oblivious to the fact that people get frustrated and, you know, it hurts. So we want to understand that they may feel powerless to make people like them. They may feel powerless to do the right thing because they make mistakes seemingly all the time. And they may have low expectations for their own success because up until now they have been trying to function in a non-FASD conducive environment. And they haven't been succeeding because their supports, their environment has not been modified to meet their needs. So we want to help them see that they are very capable of succeeding. They just need to have certain interventions and they may need to learn certain things in order to be successful in the way they want to be. Help them cope with losses and address self-esteem and any personal issues because they're going to lose friends. We all lose friends over the course of growing up. It just happens and there are other losses, but these are things that may be more difficult for someone with an FASD who has difficulty understanding actions and consequences and abstract concepts like death. Address resistance, denial and acceptance. And, well, women with an FASD may fear becoming like their mothers. They may not want to accept that they've gotten FASD and they may be terrified that they're going to become like their alcoholic mother or their mother who drank when she was pregnant. That is an important caveat I need to state. Not every woman who gives birth to a child with an FASD is an alcoholic. It does not take that much alcohol to permanently damage the fetus. So it's important to understand that, you know, the birth mother may not be an alcoholic, but she may have introduced a harmful substance to the fetus at a particularly critical time and caused the birth defects. People with an FASD may have difficulty with forgiveness of the birth mother. So they realize that they're different and they may realize that for some reason something their mother did made them different and gave them a birth defect. So they may have difficulty reconciling that relationship. It's important that we reassure clients that they're not responsible for their disability. They didn't give themselves an FASD. And some of them will think, well, if I were a better person, this wouldn't be happening or if, you know, all the ifs. So we want to reassure them that they've got strengths. They've got capabilities. This isn't their fault, but this is the hand they're dealing with. So let's figure out how to deal with it. And you don't want to use metaphors with them because they don't understand metaphors like you were dealt a bad hand. That'll just go over their head. We also want to help educate them about the science of their condition. You know, help them get into the weeds of their diagnosis and understand what they need. You know, it's like if somebody who has a physical disability needs certain modifications, it's okay to talk about that and go, this is what you need in order to help you, you know, kind of level the playing field. There's another metaphor in order to help you function the same way that other people do. Assess comprehension on an ongoing basis by asking the client to summarize what you've said and review written materials such as rules at each session. Don't assume that the client is familiar with the concept or can apply it simply because you've gone over it several times. So you want to take that concept, whatever it is, and explore their understanding beyond being able to say, yes, I'm supposed to follow my treatment plan. But what does that mean? And how is that, how can these activities help you? So having them explore it so they understand what goes into following my treatment plan. In group work, explain group expectations concretely and repeat these ideas often, preferably at the beginning of every group. If a person monopolizes conversation or interrupts, you can use a talking stick as a concrete visual reminder of who should be speaking. We've used these in groups in several facilities that I've worked in. So it helps manage the discussion. Give the person time to work through material concretely within the group time. So if they're getting overwhelmed, you may need to take a break, but you want them to be able to process the information in the group. Encourage clients to ask questions and check understanding in the material and listen for key themes to emerge so we can reinforce that. Selectively paraphrase if he says, you know, some concept, you can say exactly, and what else could you do in that situation to help them further their understanding of the concept. So if a friend asks you to go out and use drugs with them, you know, what should your response be? And they can tell you what the response would be. And then you would say, okay, what would be the next step after that? If in group, the client needs to get up and walk around, let them. And I do this with all my clients, but it's important with people with an FASD because sometimes they have difficulty controlling their impulsivity. Use concrete representations, marking the floor to show the concept of physical boundaries. I've used Legos before to represent each person. Each person has a Lego, and then we'll talk about teamwork or something and I'll have them use break up into groups. And each person's, they all combine their Legos together to come up with some sort of design or object or something. So we talk about how everybody's important and you can use water to represent energy. I've done that before where I've had a picture. Full of water and we talk about, okay, what things did you do today? And every time they talk about something they did, I pour a little water out so they can see how everything they do uses energy and why they might feel exhausted and how they can better take care of themselves. Use symbolic charts and alarm reminders for routines and role play. I know I've said that a bunch, but this is one of the ways that people with an FASD best internalize what's going on. If medication is used, simplify medication schedules and provide support. So, you know, ideally not something at weird times or every third Tuesday or I don't know what it would be. But if you can simplify, it's better twice a day. If you can do once a day, that's even better. Once a month injectables if they need antipsychotics, anything like that that can help. Find someone, something the person likes and have the person do that regardless of the behavior and that's a recommendation. Not necessarily one I would particularly use, but that was one of the recommendations in SAMHSA tip 58. Create chill out spaces in each setting where the person can go and just kind of clear their mind if they're feeling completely overwhelmed. And be creative about finding ways for the individual to succeed by setting achievable short term goals. Well, that's not super creative. And reconsidering zero tolerance policies because our clients are going to make mistakes. So if we say you make this mistake once you're out. That could be really problematic for somebody with an FASD. Now, obviously there are safety considerations, but be consistent in appointment days and times considering shorter, more frequent meetings or sessions. Give them a specific chunk of information to deal with in a 20 minute session, instead of talking about three different things in an hour session. If they're an outpatient arrange for someone to get the person to appointments for at least six months. Hopefully after six months you'll have established enough of a routine that they know what they need to do. And have the meetings on the same days each week. Discuss each meeting with the person. And for some people if it works with your schedule as a clinician and for that client using open meeting times which means I need you to come in at some point on Tuesday. Have pictures of counselors on their office doors because that helps trigger that visual for particular clients. I mean, I'm bad with names anyway. So, you know, if you're walking down a hallway with 15 different counselor names, you may be like, okay, I remember my counselor's name started with a T. But if you see a picture of that counselor, it's easier. Well, think about somebody who has an FASD. It may be probably is a lot more difficult for them to remember. So this makes it more conducive to them. Identify possible buddies to ensure that clients get to appointments if they're an outpatient. So they may need various people to transport them. Help them identify people who are appropriate supports for them as well as people who are not helpful. And this can be in treatment as well as outside of treatment. Again, we're talking about safe people versus not safe people or helpful versus unhelpful. And program important numbers and reminders into their cell phone for them with permission, of course, in order to help them start establishing this new routine. Oops. I skipped over one. Don't use metaphors or similes or any idiomatic expressions like you're a daylight and a dollar short. We use those a lot. You saw I use two or three of them in today's presentation at least people with an FASD don't understand those concepts so it's important to stay concrete and very literal. And don't use sarcasm because a lot of times it's misinterpreted as honesty. They don't understand the difference with sarcasm. So in summary, with people with an FASD about age 12 to 21 normal development, they can evaluate their own behavior in relationship to the future and understand their consequences consequences of their behaviors. In FASD, there's a lack of connection between thoughts feelings and actions they may want to do something and impulsively do it, not understanding the consequences. So, to address that we want to repeatedly, or have repeated skills training with role playing and videotaping, let the person rewatch the videotapes of themselves doing it right. And if they do it incorrectly, and I try to avoid using the word wrong, they do it incorrectly, then we want to go back and look at why did they do it incorrectly what things triggered them to choose an alternate alternative reaction. In age 12 to 21 in normal development, there's an important peer group and development of intimate relationships, you know, high school, this is what we're talking about in college. With a person with an FASD they have difficulty resisting negative peer influences and accurately interpreting social cues. So they have difficulty establishing a healthy supportive peer group, let alone intimate relationships. So it's important that we help them connect with pro social peers, mentors and coaches who will help them establish a network and provide social skills training with repeated discussions of sexuality and intimacy as appropriate in order to prevent a misunderstanding of nonverbal cues and potentially unfortunate behavior choices. Additional modules on FASD will focus on topics including accommodations for the clinician to prevent exasperation and burnout, FASD in the criminal justice system, and case management and unmet needs for caregivers. Got through that one. All right, I saw a few people comment in here. And yes, there is an awful lot of overlap between FASD and autism for a long time. FASD was lumped into the autism spectrum. Now we have FASD as its distinct entity, but it is important to understand that there is some overlap. More important is to understand that it is a biological as well as a cognitive issue. So it needs to be addressed and treated from a multidisciplinary perspective. There are links in the class to help you connect with some of the FASD centers for excellence so you can learn more about the assessment process and what happens. There are literally thousands of pages of material that you could read if you are interested in this particular topic. And yes, there are physical characteristics of people and generally, not always, but generally they don't start showing up until the more significant end of the spectrum. And again in SAMHSA, let's see, I can pull that up real quick. In the SAMHSA tip, they do talk some about that. One thing they have come forward since I really started learning about FASD is initially when they started identifying the facial features of someone with an FASD, they did not take into consideration ethnicity or, you know, certain differences by gender. So they're refining that criteria, but it's important not to rule someone out simply because they don't have the facial features for an FASD. Let's see, I might be able to find a graphic of it really quick. Sorry, that's a Google link. There are several images that can point you towards some of the things that a pediatrician or family physician may be looking for and that we can keep an eye out for in terms of tips that someone may have FAS as opposed to something else or in addition to something else. Telling the difference between FASD and autism really requires the multidisciplinary team to get in there, do an assessment about specifically what kinds of things trigger the person and what skills and the history of the pregnancy and all kinds of stuff like that. And I am not educated enough about diagnosing autism to tell you any more specifically than that if, let's see, I think tip 58 does talk some about it. I'm going to look that up real quick. Universal prevention. No, actually they do not talk about diagnosis in the tip. Mainly because it's not something that we as independent clinicians can do. I will add that to the second section. Just for a counselor's perspective on how to know the difference or what the differences are between FASD and autism, in addition to survival tools for the clinician. Alrighty everybody have a wonderful afternoon and I will see you on Thursday. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com slash counselor toolbox. This episode has been brought to you in part by allceus.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006. Use coupon code, counselor toolbox to get a 20% discount off your order this month.