The Case for Triple Diagnosis SANDAS Symposium Wednesday September - - PowerPoint PPT Presentation

Sue Miers AM Founder NOFASD Australia

Fetal Alcohol Spectrum Disorders The Case for Triple Diagnosis

SANDAS Symposium Wednesday September 28th 2016

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Parents/Carers struggle to find effective counselling options for adolescents/adults with FASD or suspected FASD who have substance dependency and/or mental health issues

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Irish Psychiatrist Kieran D. O'Malley in ADHD and Fetal Alcohol Spectrum Disorders (FASD) “Co- morbidity is the rule rather than the exception in patients with FASD. It often begins in infancy, continues through the lifespan, and may change over time due to environmental stressors”

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Primary characteristics

• Impaired Judgement
• Lack of understanding cause and effect
• Inability to learn from mistakes
• Mood swings (confused, distorted thinking,

anger management issues, anxious)

• Attention problems
• Impulsivity, lack of self control

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Primary characteristics

• Confabulation without deception
• Stealing without deception
• Inner locus of control faulty or missing
• Unable to take responsibility for actions –
• ften blame others

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Understanding the impact of FASD

FASD is a complex learning disorder affecting multiple domains of functioning including working memory, attention, impulsivity, learning, interpersonal relatedness, social skills and language development.

O’Malley 2008

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There is a huge lag between chronological and developmental age irrespective of their IQ

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FASD can be masked by co-

• ccurring disorders

Adhd, autism, schizophrenia, depression, bi- polar disorder, substance use disorders, sensory integration disorders & reactive attachment disorder, separation anxiety, PTSD, traumatic brain injury, risk for borderline personality disorder. Also medical disorders - siezures, heart abnormalities, cleft lip & palate.

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Secondary issues

• Not completing school/training programs
• Drug & Alcohol Dependency & Mental

Health issues are the rule rather than the exception

• Problems acquiring and maintaining

housing

• Employability/financial issues

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Secondary issues

• Relationship problems/family & domestic

violence

• Health problems, reproductive issues
• Problems with social compliance and the

law – incarceration a common outcome

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Why we need to recognise FASD

• The correct diagnosis provides a lens through

which we can gain an understanding of the whole story & formulate targeted treatment plans

• Recognition of the depth of the problem is

imperative for future prevention

• Recognition of FASD provides alert for the

possibility of other underlying medical conditions

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Aus FASD Diagnostic Instrument

• Published in May 2016
• A copy is available on the Australian

Paediatric Surveillance Unit website http://www.apsu.org.au/assets/Uploads/2 0160505-rep-australian-guide-to-diagnosis-

• f-fasd.pdf

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Aus FASD Diagnostic Instrument

On-line learning Modules for Clinicians http://alcoholpregnancy.telethonkids.org.a u/australian-fasd-diagnostic-instrument/

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FASD in AOD & Mental Health

• Practice based evidence tells us it is

important to modify approaches for those who we suspect have FASD.

• Difficulties often present as behavioural

challenges & understanding is essential in telling us how to intervene.

• There may also be contraindications for

pharmaceutical interventions

(O’Malley 2008)

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FASD Diagnosis in adults

• Current diagnostic capacity is limited
• In an ideal world screening would lead to

an assessment and diagnostic evaluation

• Current lack of diagnosis and appropriate

treatment and support is resulting in extremely devastating outcomes including incarceration and death.

• A life history screen can be very helpful

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Life history Screen for FASD

• Published in the International Journal of Alcohol

& Drug Research (2013)

• Aside from demographics there are 28 questions

in 9 categories - expected that these questions will be asked over several sessions

• The screen is meant to be a guide for

modifications in treatment approach

• The screen needs to be validated for sensitivity

and specificity

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Why not just treat presenting behaviours?

Visual reminders

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FASD – “red flag” indicators

• Friendly, likeable, “talk the talk” & seem to want

to please, but often don’t follow through

• Appear very bright but exhibit immature

behaviour when stressed or under pressure

• Good expressive language but history of poor

school performance, not living with family of

• rigin, unstable accommodation/homelessness,

relationship problems, financial issues, contact with the legal system

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FASD – “red flag” indicators

• May have a diagnosis of ADHD, ADD, ODD,

RAD, a MH diagnosis, other dependency eg problem gambling

• Inconsistent attendance, and a history of

being turned away from other programmes

• May give inconsistent versions of events

(confabulation)

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What can Service Providers do?

Paradigm Shift – If FASD need to understand

• They have a brain injury
• Unable (not unwilling) to always take

responsibility for their actions

• Unable to learn from experiencing

consequences

• Not able to always control their behaviour

and they are not making informed choices

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What can Service Providers do?

Paradigm Shift –If FASD:

• Independence may not be possible without

intensive support

• Helping to make & keep appointments or

taking to appointments is not enabling dependency it is providing the accommodations needed to achieve success

• .

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What can Service Providers do?

• Upskill all staff so that FASD is included in

their assessment and skills repertoire

• Value parent/carer experience
• Develop understanding of the impact of

FASD across the lifespan

• Recognise importance of key agency taking

responsibility for case management

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Strategies for Success

• Modified counselling sessions – longer

process more frequent appointments, watch for sensory overload

• Concrete language – directive, limit need

for receptive language skills, use visuals

• Consistency – appointment days and times,

phone reminders, limit & prepare for staff changes

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Strategies for Success

• Reality based therapy - Role play and social

stories

• Review and repetition important
• A positive “try again” attitude – remember

that ‘falls” do not necessarily signify lack of desire to change

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Strategies for Success

• External system of support to enable them to

manage challenging situations and daily living

• skills. These issues may include parenting,

employment, housing, educational training and social behaviour

• Adapt the environment instead of trying to

change the person. Addressing daily living needs (as well as removing access to substances) is far more beneficial than insight work for these persons

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Strategies for Success

• Primary treatment goals should include

realistic living arrangements, sheltered work environments & life skills enhancement

• Relapse prevention - focus on increased

supervision & community supports

• Ongoing lifetime supports usually

necessary - ongoing “booster” counselling sessions

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Practice based evidence tells us:

• Group therapy & dredging up past may cause

enormous trauma & be overwhelming

• Insight Therapy is very difficult for them to

comprehend – too cognitive

• Cognitive behavioural therapy ineffective unless

modified for clients social/emotional/developmental age

• “Rewards, incentives, punitive consequences”

ineffective unless absolutely immediate

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Final thoughts to keep in mind

• FASD crosses every system of care - developing

true collaborative cross agency & systems relationships is essential

• Correctly recognizing & addressing FASD can

reduce long term costs & improve outcomes for the individual, family, agency, & systems

• By successfully intervening with substance using

women who have FASD themselves or a child with FASD we can reduce the incidence of further alcohol exposed pregnancies

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• References
• ADHD and Fetal Alcohol Spectrum Disorders (FASD) Kieran D. O'Malley (2008) Nova Science

Publishers (Co-Morbidity in FASD: Dual & Triple Diagnosis p 11).

• Streissguth, A.P., Barr, H.M., Kogan, J. & Bookstein, F. L., "Understanding the Occurrence of

Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE)," Final Report to the Centers for Disease Control and Prevention (CDC), August, 1996, Seattle: University of Washington, Fetal Alcohol & Drug Unit, Tech. Rep. No. 96-06, (1996).

• Dubovsky (2014) HIS Webinar accessed online -

https://ihs.adobeconnect.com/p7c4p1sm8wy/?launcher=false&fcsContent=true&pbMode=nor

• Grant TM, Novick Brown N, Dubovsky D, Sparrow J, Ries R. “The Impact of Prenatal Alcohol

Exposure on Addiction Treatment.” Journal of Addiction Medicine 2013; 7(2) 87–95.

• Grant TM, Novick Brown N, Graham JC, Whitney N, Dubovsky D, Nelson LA.“Screening in treatment

programs for Fetal Alcohol Spectrum Disorders that could affect therapeutic progress.” International Journal of Alcohol and Drug Research 2013; 2(3) 37-49.

• Guidelines on the management of co-occurring alcohol and other drug and mental health

conditions in alcohol and other drug treatment setting https://comorbidity.edu.au/sites/default/files/National%20Comorbidity%20Guidelines%202nd%20 ed%20corrected.pdf

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Thank You

NOFASD Australia (National Organisation for Fetal Alcohol Spectrum Disorders Australia) telephone: 1300 306 238 email: admin@nofasd.org.au website: www.nofasd.org.au Patron: The Honourable Quentin Bryce AD CVO ABN : 93 833 563 942