Elements of Success: Helping Individuals with
and Co-occurring Disorders
Bay Retreat Center – FAS*FRI Conference
Cognition and Behavior
from Presentation by Ann Streissguth. Ph.D
brain is the most vulnerable organ affected by prenatal alcohol exposure.”
and Driscoll’s study in 1990 showed that the behaviors that we see in children
with a history of prenatal exposure to alcohol are the same as those seen in
animals exposed to prenatal alcohol, so we know these effects are caused by
alcohol independent of environmental factors.
There are reports that show evidence of alcohol effects in monkeys and
fruit flies. Someone stated that a
study with spiders exposed to different substances, where alcohol had the most
adverse effects of all.
are birth defects of the brain.” We
set up diagnostic clinics, but we are getting the children too late, they are
missing out on the early intervention services that can make a big difference in
outcome later. Countries like
Sweden that have health care for all do not have a big problem with FASD because
it is dealt with in prenatal care. In
the U.S. we have more problems with FASD and we have a very high death rate for
WISC, WAIS, WRAT may not show the severity of deficits in FASD.
When doing the VABS on individuals with FASD, the score is 2 standard
deviations below the person’s own IQ, and even more so when compared to
general population. IE, IQ of
person with FAS might be 80, and the Vineland score would be 60.
Fetal Alcohol Behavior Scales (FABS) designed by Streissguth is based on
behaviors observed in those with a diagnosis.
Habituation (difficulty modulating incoming stimuli)
over stimulated in social situations
to situations with strong emotional response
swings set off by small things
trouble completing tasks
cause and effect reasoning in social situations
of consequences of own behavior
judgment about whom to trust
with poor timing
take a hint
be the center of attention
persons who have a diagnosis of an FASD but have a normal IQ, scores are below
normal in certain attention tests: COWAT (shifting sets), RUFF (perseveration),
CVLT (free recall intrusions, adds to stories). In some attention tests, they do well while there are no
distractions, but when distractions were added, they scored 1-2 standard
deviations below normal.
does not fit the MR model, but it fits better with the model for Traumatic Brain
persons with FASD, problems with Executive Functions are much worse than those
with similar IQ.
Implications for Adolescents and Adults with FASD
What this means for them:
Easily victimized (and then becomes victimizer)
Cannot manage money
Difficulty learning from experience
Cannot figure out the consequences
in time and space
tolerance Quick to become angry
Study of Individuals with Prenatal Exposure to Alcohol:
outcomes show poor suck, latency in beginning to such (delayed response to
nipple), poor reflexes. Leading
indicator is poor habituation to light, which is related to later learning
scales on babies at 18 months did not detect effects. This is NOT the time to test.
4 years of age, we can detect difficulties in areas of attention, arithmetic,
processing time, latency to correct errors, poor balance, perseverance, verbal
interruptions, hypertonic (some can be hypotonic).
age 4 to 14, behavioral differences are seen in laboratory (blind tests) in
these areas: distractible, uncooperative, rigid, seeks reassurance,
disorganized, impulsive (14).
rating shows problems with cooperation, impulsivity, memory, attention,
unpredictable behavior. The same
results were observed at 21 years of age.
We have failed in identification of FASD in time for early intervention to prevent secondary disabilities. We have failed in getting relevant help when they are in the institutions and facilities when they are most vulnerable (schools, mental health, criminal justice system). And we have failed to provide adequate services and supports for the families caring for then.
for Public Health Model to initiate Neonatal Health Study to look at the corpus
callosum of newborn through fontanel ultrasound ($150, nonintrusive, mother can
observe and be informed immediately to access early intervention services).
Pilot study shows ability to accurately detect FASD in half of newborns
prenatally exposed to alcohol.
need to initiate the following:
program and transitional resources for affected individuals
in Behavioral Health System
programs to identify FASD in persons getting mental health services and measure
newborns with fontanel ultrasound (described above)
services and supports to families caring for children and adults with FASD
FASD in the Adolescent Developmental Process
from Presentation by Dr. Charles Huffine
Bay Conference Center – FAS*FRI
is the language of adolescence, the primary medium.
job is sometimes to put the breaks on what they do.
Adolescents need an arena of safety and supervision in which to explore.
When they don’t have this, things can go wrong (poverty, obesity,
Overprotection and underprotection can both have potential to be
is a cause of distress in adolescence.
There is a large variability among youth with FASD.
in teens: what should parents do?
Good assessment of strengths and needs
For those whose children have severe intellectual and medical
Find or create resources where the child can maximize the adolescent
Help child accept their realities and work around them, recovery process
Demand resources from schools, medical care, mental health, eventually
with more subtle disabilities:
Be aware of your child’s capacity to exercise judgment, for social
Exercise higher degree of caution based on assessment of capabilities.
Flexible approach: accept that growth can occur, negotiate and reassess
Youth with FASD make mistakes, but it’s not always the end of the
can celebrate that they are out there being kids.)
may over assess the risk of alcohol use and drug use among teens.
Marijuana is far less dangerous for youth.
vs wisdom in dealing with emerging sexuality.
fear of juvenile justice system, discipline, neighbors’ judgment.
teens with FASD should do:
Push as hard as you can to have freedom to take usual teen risks (if they
don’t, they are probably depressed).
Try to figure out the “rules” in social groups and ways infractions
are punished by teen sanctions
Find adult mentors with whom to figure out confusing social dilemmas
(older adults mentor younger kids, like the crazy aunt that the kids love)
Come to understand one’s “wiring” presents risks for impulsivity,
judgment, and being slow to learn
Maximize assets: i.e. charm, desire to please, being cute or strong,
that teens with FASD should do but are often reluctant:
Accept help at school from tutors, resource rooms, special ed
Using trained mental health professional as an adult mentor
Negotiate with parents based on common understanding of the problems
Learn from constructive peer feedback
Accept, normalize, learn about FASD
Neuropsychological Issues in Fetal Alcohol Syndrome
from Presentation by Gayle Fay, Ph.D.
Bay Conference Center – FAS*FRI
kinds of arousal are generated by the mind’s reaction to the environment:
Energy to focus and concentrate
Energy to fight, flee, or freeze (reaction to stress)
latter has the capacity to obstruct the former.
Children with FASD are often under great stress.
a child or adolescent is overloaded with arousal, they cannot actively pursue
the circuits are overloaded, their ability to make sensible decisions is
They will become increasing impulsive, disorganized, and inappropriate.
Crucial for nearly all cognitive abilities
Defined as “online maintenance of convergent information coming from
This is managed on the neurological level of the brain and very difficult
for a person with brain injury.
Attention is not a single or isolated cognitive function
Selective/focused attention requires the ability to:
Sort though information
Identify the relevant elements of the task
Sustained attention: ability to keep one’s mind on the job
Attention switching (dual attention)
This is not obsessive behavior, but is rigid behavior.
They can manage to keep their attention for about 4 to 6 minutes.
Issue: Thinking and Problem Solving in the Real World
Poor abstract thinking (reasoning)
Know-do dissociation (“He knows what to do because he told me exactly
what he was supposed to do.”)
Coach them through the exact performance of the endeavor.
Inability to transfer, generalize information (generalizations have to be
absolutely and specifically taught)
Poor judgment and decision making
has to be a critical goal on the IEP for students at all ages.
Issue: Speed of Thinking and Synchronization
Lengthy latency to response
Slowed uptake and assimilation of information (teacher is on D,E,F and
student is still working out A,B,C; television show, may lag processing what
they are watching)
Unduly rapid uptake and assimilation of information; unduly rapid output
of information (non-reflective response style) (inappropriate behavior and
Issue: Self Regulation
Biological: Inability to regulate arousal (neurofeedback helps them learn
to modulate arousal, at least gives them an idea of what a stable arousal state
Neuropsychological Issue: Self Regulation – Behavioral
Impaired monitoring of behavior (reality testing)
Excessively bound by environment cues (cannot think beyond the situation,
therefore easily manipulated)
Distorted internal models of past, present, and future environments
(cannot draw on prior experience)
can be coached by specific, nonjudgmental cues to respond appropriately.
Issue: Speech Language Skills
Impaired auditory processing
Issues with retrieval and elaboration
Use fewer words
Use phrases instead of sentences
Inextricably intertwined with arousal, attention, cognition, and emotion
Systems: episodic, visual, verbal, procedural (memory for rules and
Issue: Working Memory
Manipulation of online information
Relate information to experiential base
Ability to reorganize mental context
Issue: Thinking Flexibly
Cannot shift focus between external events or between external events and
Results in perseveration (repetitive responses) (hyper-arousal from
stress = stuck)
we see are neurological, not psychological
Issue: Physical/Mental Endurance
High levels of arousal, challenge, and anxiety sap physical and mental
Many FAS children show heightened levels of hyperactivity when endurance
Issue: Social Pragmatics/Social Communication
superb executive and information processing skills (recognition of subtle social
impossible, but needs to be embedded into their neurological program from an
Through the Lens of a Child Psychiatrist
FASD from Other Co-occurring Disorders
from Presentation by Dr. Susan Rich (MD, MPH)
Bay Conference Center – FAS*FRI
Rich is an MD and also MPH, board certified psychiatrist in Washington DC and
describes herself as an impassioned person on a journey who offers her resources
in the area of health policy on a national basis.
Link between ADHD and FASD
Clinical subtype of FASD
may exist within the population of individuals with ADHD
Nearly every individual
with FASD has some form of attention deficit
Caution in use of
stimulant medications for individuals with co-morbid heart conditions
clinical trials in this population (comparing FASD to garden-variety ADHD)
Other Psychiatric Disorders
OCD co-occurring with
Tourette’s syndrome may be more common in individuals with FASD
Autistic behaviors have
been noted in younger children and school age children prenatally exposed to
alcohol HHS report to Congress, June 2000)
There is a subset of
children with diagnosis of Autism who should be considered for FASD
Functional Birth Defects:
standard drink per day in pregnancy is linked to attention deficits in the child
Public health Issue: Need to prevent the Epidemic caused by our social drug of choice!!! Focus on Preconceptual Health.
Behaviors in ARND
Common secondary disabilities in children and adolescents with ARND
Peer pressure (boys
become delinquent, girls have unintended pregnancies)
Easily victimized child
abuse, incest, abduction)
Trauma and injuries