FASD and Co-Occurring Disorders Dan Dubovsky M.S.W. FASD Specialist SAMHSA FASD Center for Excellence
The Benefits of Appropriate Identification and Treatment of FASD Helps decrease anger and frustration by helping people understand that negative behavior results from the disability and is not willful Helps people with an FASD succeed by focusing on their strengths and what will help them, not on their weaknesses and what they have done wrong Helps improve outcomes for individuals, families, agencies, and systems
Consequences of Not Recognizing an FASD in an Individual These individuals often fail with typical education, parenting, treatment, justice, vocational, and housing approaches They often live in multiple living arrangements throughout their lives At 18, 22, or earlier, they are on their own without the supports necessary to succeed in the community
Consequences of Not Recognizing an FASD in an Individual They keep failing with typical approaches to parenting, education, treatment, vocational training, etc. They think they are just bad or stupid We use these typical approaches, including verbal communication and reward and consequence systems These put the person at high risk of ending up homeless, in jail, or dead
Consequences of Not Recognizing an FASD in an Individual Adults are often repeatedly in treatment settings having failed in treatment Multiple admissions for substance abuse treatment Multiple admissions for mental health treatment They repeatedly have difficulty in employment They get into repeated trouble with the law Especially for committing the same crime more than once and/or repeatedly breaking probation or parole They are frequently homeless
Consequences of Not Recognizing an FASD in a Caregiver Caregivers with unrecognized FASD are often labeled as neglectful, uncaring, or sabotaging Especially in child protective services, substance use is an issue in many families who come into care We place their children We tell the parents what they need to do to get their children back Completion of multiple tasks is expected They say they know what they need to do, but they do not follow through on instructions We threaten termination of parental rights
Consequences of Not Recognizing an FASD in a Caregiver They fail in temporary assistance programs that are time limited and based on the concept of willful behavior and motivation as the key to success They fail in typical treatment and parenting programs The children remain in temporary placement or parental rights are terminated Women may have another child with an FASD
Challenges for Providers in Recognizing FASD Recognizing an FASD challenges the basic tenets of interactions with people in every arena That people need to take responsibility for their actions and learn by experiencing the consequences of their actions That people are in control of their behavior If a person says that she or he knows what to do and then does not do it, it is because she or he does not want to do it
Challenges for Providers in Recognizing FASD Recognizing FASD challenges are the basic tenets of interactions with people in every arena That enabling and fostering dependency are to be avoided in treatment A person has to learn to do things on her or his own because that s the real world
Challenges for Providers in Recognizing FASD Because of the brain processing issues in FASD, these individuals do not tend to learn by experiencing the consequences of their actions Natural consequences are often ineffective and may put the person at risk of being homeless, in jail, or dead However, this is the basis of many of our interventions in parenting, treatment, education, vocational services, child welfare, and corrections
Challenges for Providers in Recognizing FASD In order to improve outcomes for this population, the concepts of dependency and enabling as negative terms need to be re-thought Getting someone to their appointment or filling out forms with them may improve their outcomes
Challenges for Providers in Recognizing FASD People with an FASD are often challenging to work with They often say they know what they need to do and do not follow through They break the rules often They are surprised when they are in trouble They are viewed as being non-compliant, uncooperative, and unmotivated Treatment of co-occurring issues must be different, if a person also has an FASD
Co-Occurring Disorders or Co-Occurring Issues? Co-Occurring disorders refers to diagnosable disorders Most often refers to mental health and substance use disorders recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) Many people with a disability have issues with which they struggle that go beyond disorders If we do not address all co-occurring issues with which a person is dealing, we will not get optimal results in our treatment, education, vocational, or other services
D Dubovsky 2010
D Dubovsky 2010
Likely Co-occurring Disorders with an FASD Attention-Deficit/Hyperactivity Disorder Schizophrenia Depression Bipolar disorder Substance use disorders
Likely Co-occurring Disorders with an FASD Sensory integration disorder Reactive Attachment Disorder Separation Anxiety Disorder Posttraumatic Stress Disorder Traumatic Brain Injury Risk for Borderline Personality Disorder Medical disorders (e.g., seizure disorder, heart abnormalities, cleft lip and palate)
Possible Misdiagnoses for Individuals With an FASD ADHD Oppositional Defiant Disorder Conduct Disorder
Comparing FASD, ADHD and ODD D Dubovsky (2002)
Comparing FASD, ADHD and Conduct Disorder D Dubovsky (2003)
Comparing FASD, ADHD and Conduct Disorder D Dubovsky (2003)
Possible Misdiagnoses for Individuals With an FASD Adolescent depression Bipolar disorder Intermittent Explosive Disorder Autism/High Functioning Autism Reactive Attachment Disorder Traumatic Brain Injury Antisocial Personality Disorder Borderline Personality Disorder
Comparing FASD, Adolescent Depression and Adolescent Bipolar Disorder D Dubovsky 2006
Similarities Between FASD and Autism Both are developmental disabilities Both affect normal brain function, development, and social interaction In both, the individual often has difficulty developing peer relationships
Similarities Between FASD and Autism In both, there is often difficulty with the give and take of social interactions In both, there are impairments in the use and understanding of body language to regulate social interaction
Similarities Between FASD and Autism In both, there is difficulty expressing needs and wants, verbally and/or non-verbally A short attention span is often seen in individuals with Autism and an FASD In both, we may see an abnormal sensitivity to sensory stimuli, including an over- or under-sensitivity to pain
Differences Between FASD and Autism
Differences Between FASD and Autism
Differences Between FASD and Autism
Differences Between FASD and Autism
Child & Adolescent Development Issues in FASD (Age 0-18 months) Dubovsky, Dan (2001)
Child & Adolescent Development Issues in FASD (Age 18-36 months) Dubovsky, Dan (2001)
Child & Adolescent Development Issues in FASD (Age 3-6 years) Dubovsky, Dan (2001)
Child and Adolescent Development Issues in FASD (Age 6-12 years) Dubovsky, Dan (2001)
Child & Adolescent Development Issues in FASD (Age 12-21 years) Dubovsky, Dan (2001)
A Strengths Based Approach to Improving Outcomes Identify strengths and desires in the individual What do they do well? What do they like to do? What are their best qualities? What are your funniest experiences with them? Identify strengths in the family Identify strengths in the providers Identify strengths in the community Include cultural strengths in the community
Strengths of Persons With an FASD Friendly Likeable Verbal Helpful Caring Hard worker Determined Have points of insight Good with younger children* Not malicious Every day is a new day D. Dubovsky, Drexel University College of Medicine (1999)
Final Thoughts to Keep in Mind We want to help people succeed Whatever it takes is an important attitude Ask the question: What does this person need in order to be successful (function at their best) and how do we help them achieve that? Positive outcomes for the person means positive outcomes for agencies and systems We need to foster interdependence FASD is a human issue
FASD Is a Human Issue FASD is about people. Do not lose sight of that FASD affects the lives of individuals, families, and communities It s essential to really care People with an FASD and their families have great potential We need reminders of what has been accomplished Especially when things are not going well
Resources SAMHSA FASD Center for Excellence: fasdcenter.samhsa.gov Centers for Disease Control and Prevention FAS Prevention Team: www.cdc.gov/ncbddd/fas National Institute on Alcohol Abuse and Alcoholism (NIAAA): www.niaaa.nih.gov/ National Organization on Fetal Alcohol Syndrome (NOFAS): www.nofas.org National Clearinghouse for Alcohol and Drug Information: ncadi.samhsa.gov