Positive Approaches Journal, Volume 12, Issue 2
Dubovsky | 43-48
Volume 12 ► Issue 2 ► August 2023
Optimizing Outcomes by Recognizing and Responding to Fetal Alcohol Spectrum Disorders
Dan Dubovsky, MSW
Fetal Alcohol Spectrum Disorders (FASD) are caused by the effects of alcohol on a developing embryo and fetus. As alcohol is a legal drug and is frequently consumed, the effects of alcohol on an unborn child are not universally recognized, about half of all pregnancies are unplanned, and people are most often not aware of when they first become pregnant, FASD are more common than many other disorders and are much more common than most people think. Although there is a great amount of stigma regarding FASD, people who are pregnant do not intend to harm their unborn children. The current generally accepted prevalence is 1 in 20 or 5%. However, recent studies in the U.S. (May P, Chambers C, Kalberg MA, et al. (2018). “Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities.” Journal of the American Medical Association: 319(3) 474-482) have found the weighted prevalence to be as high as 1 in 10. This is especially significant in our specialized services as the prevalence is often even higher in settings such as developmental disabilities, intellectual disabilities, special education, mental health, vocational rehabilitation, and corrections.
The diagnostic capacity for FASD is miniscule compared to the prevalence. FASD is therefore often not recognized. As a result, behaviors such as not following through with multiple instructions or directions, overreacting to minor stressors, acting aggressively, and having repeated tantrums or rages are seen as willful and purposeful behaviors. However, due to the effects of prenatal alcohol on the developing brain, behaviors that individuals with an FASD often demonstrate are due to how their brain is functioning. These individuals frequently receive other diagnoses, which may be misdiagnoses or true co-occurring issues. However, no matter which it is, the treatment will not be effective if the FASD is not correctly recognized and integrated into approaches. Therefore, it is essential to be able to recognize FASD, and the earlier it is identified, and appropriate approaches are implemented, the better the long-term outcomes for the individual, family, providers, and systems of care. Understanding brain structures that are affected by prenatal alcohol and the functions of those structures helps us understand the behaviors of those with an FASD differently and change our approaches with this in mind. For example, as the part of the brain responsible for immediate or working memory is often impaired, instead of giving someone multiple instructions, directions, or rules, it is more effective to provide one step at a time.
As a result of this imperative to identify FASD, it is vital to utilize a screening/assessment approach to identify those individuals with a probable FASD and implement modifications to approaches as early as possible. With this in mind, two colleagues of mine at the University of Washington and I developed the Life History Screen (LHS) to identify older adolescents and adults with a probable FASD. The LHS has 32 questions in 9 categories. It was developed based on statistically significant differences in responses to these questions in categories such as childhood history, prenatal alcohol exposure, day to day behaviors between those with and without an FASD (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). The draft screen was tested by 22 residential substance use treatment programs in several states, the results of which identified the key categories as those mentioned above. Additional categories included education, living situation, employment and income, and substance use. The screen is administered by an FASD trained individual after training on the screen, how it is introduced, and how to ask questions in a way to promote honesty and minimize stigma. Although this screen is not diagnostic, a German study (Shwerg and Ahlert (2018) presentation at the 8th International Research Conference on Adolescents and Adults with FASD, Vancouver BC) found that it was 92.8% accurate in identifying those with or without an FASD.
Once a person receives a positive Life History Screen, modifications need to be implemented based on the scientific understanding of brain processing issues in FASD due to the effects of alcohol on the developing brain. Behaviors that appear to be willful and purposeful may well be due to damage to certain brain structures. If that is the case, typical reward and consequence approaches will not improve those behaviors. The LHS and modifications approach has been utilized in adult treatment settings with positive shifts in understanding on the part of staff regarding behaviors and how best to address them. Modifications are based on an understanding of brain processing in individuals with an FASD and include approaches that modify the environment to help the individual reach their optimal potential rather than expecting the individual to change his or her behavior. In addition to providing one direction at a time as mentioned above, utilizing repeated role playing, being consistent in routines, utilizing multiple senses such as visuals and tactiles rather than relying on verbal approaches, providing a mentor as a positive role model, and simplifying the environment.
In 2017, the State of Michigan wanted to implement a screening and assessment approach to identify youth who come through the public mental health system who may well have an FASD. To this end, a quick 5-6 question screen that could be implemented by a trained intake worker for families of children Birth-5 and 6-21 was developed, along with a modification of the Life History Screen. A positive brief screen would lead to an assessment utilizing the modified LHS completed between a trained clinician and the family and older youth. A positive assessment would lead to two main interventions, either Families Moving Forward, an evidence-based practice developed by Heather Carmichael Olsen at the University of Washington, or Strengths and Strategies, an evidence-informed practice developed by Dan Dubovsky in collaboration with Kathy Fitzpatrick, the FASD Initiative lead at the State of Michigan Department of Health and Human Services. Families Moving Forward is a manualized approach working with parents of children with an FASD 3-13 years old to build an understanding of the basis of the child’s behavior and respond differently to improve outcomes. Strengths and Strategies begins by identifying strengths in the individual, family, providers, and community and utilizing those in combination with strategies based on the understanding of brain functioning to modify the environment and improve functioning for those with an FASD.
In Pennsylvania, we have been able to collaborate with Luzerne. Wyoming, and Crawford Counties to implement the screening, assessment, and strengths and strategies approach in Children’s Service Center in Luzerne and Wyoming and the Juvenile Probation Office in Crawford County. Staff are trained in FASD and in the use of the screen and assessment, a strengths assessment, and strategies to address challenging behaviors. Regular coaching calls with staff were also provided to address specific issues and situations.
This approach of identifying and utilizing strengths in the individual along with strategies based on brain processing to address challenging behaviors and educating families and other providers to understand the basis of behaviors in FASD, has resulted in positive outcomes for many, including lowering a risk of family disruptions and improving behaviors in the individual. The key is helping those living or working with a person with an FASD to understand that we need to modify the environment in order to help the individual reach their best potential rather than expect the individual to change their behavior if they are motivated.
Dan Dubovsky, MSW, has worked for over 50 years in the field of behavioral health as a direct care worker in residential treatment and a therapist in residential, hospital, and outpatient settings. For over eight years, he was an Instructor in Psychiatry in the Division of Behavioral Healthcare Education, writing and teaching courses on child and adolescent development, loss and grieving, schizophrenia, mood disorders in children and adolescents, youth and violence, transition, fetal alcohol spectrum disorders, and psychopharmacology among others. He has been involved in fetal alcohol spectrum disorders (FASD) for over 35 years. For 14 years he was the FASD Specialist for the Substance Abuse and Mental Health Services Administration (SAMHSA) FASD Center for Excellence until its funding was eliminated. For the past several years, he has focused on the development and implementation of a screening, assessment and modification protocol for children, adolescents, and adults to help individuals and families reach their best potential. For his work in FASD, his son Bill has been his mentor and best teacher. He is currently an independent contractor providing training and technical assistance throughout the U.S. and Canada.
Dan Dubovsky, MSW
FASD Specialist email@example.com