Thoughts on Treatment of Adults and Adolescents Impaired by Fetal
Alcohol ExposureThoughts on Treatment of Adults and Adolescents Impaired by Fetal
Alcohol Exposure
This is the second in a two-part series on identifying and helping patients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE) in treatment settings. The first article focused on how to identify these clients at intake. (Treatment Today Fall 95, Vol.7, No.3, p.14)
This article addresses therapeutic interventions that work well for patients with FAS/FAE -- particularly in the inpatient setting, in the transition period and for long-term support.
By the time people with FAS or FAE reach adulthood, many of the physical characteristics (e.g., facial features and growth deficiencies) may no longer be apparent. Consequently, it is the history of prenatal alcohol exposure and the behavioral manifestations of central nervous system dysfunction that provide the clinician with the primary clues to the suspected diagnosis. These behaviors include impulsivity, poor social skills, rigid "black and white" thinking, poor judgment, deficient organizational skills, inability to plan ahead, inadequate emotional control and difficulty in recognizing and setting boundaries. Because of these problems, many individuals affected by prenatal alcohol exposure end up in dysfunctional living environments, mental health facilities, treatment centers for alcohol and drug addiction, prisons, jails or homeless on the streets. If an individual is fortunate enough to be in a facility where staff recognize the problem and can provide the appropriate support, there is a better possibility for a positive outcome.
Inpatient treatment programs generally include several components, some of which are better suited to meet the special needs of individuals with fetal alcohol impairment. Traditional group or milieu therapy may be disorienting and upsetting to patients with FAS/FAE due to their difficulty with boundaries, emotional control and suggestibility. They often respond more successfully to a mentoring, one-on-one type of treatment where they feel a special bond with a staff member who serves as their advocate and point of contact. While insight-oriented treatment is often lost on patients with FAS/FAE, individual therapy can be specifically designed to address treatment issues in a more structured way. Cognitive-behavioral approaches work best, because they can be specifically tailored to accommodate the judgment and organizational problems of the patient identified as having FAS/FAE. Instead of relying on an individual's ability to generalize what he or she learns in treatment and to modify behavior accordingly, a more effective approach involves the use of consistent rules of behavior that guide and structure behavior in any situation. For example, in the case of a treatment issue involving alcohol abuse, a provider might develop a list of high risk situations (e.g., taverns) with the patient and a specific rule that addresses how the patient is to respond to each situation (e.g., staying out of all taverns or places where alcohol is served).
Rules or guidelines can work well for specific behaviors, but a far more difficult area for most people with FAS/FAE is how to handle emotions. Individuals impaired by prenatal alcohol exposure often exhibit rapid mood swings and quick tempers. When these characteristics combine with a generally impulsive nature and a history of repeated frustration, behavior control is difficult. If this pattern of emotional responses is not addressed appropriately in treatment, treatment success and post-discharge outcomes are generally poor. As with behaviors, individual therapy is best-suited to deal with the issue of emotion control. Role-playing is an effective technique. In this approach, the therapist develops a number of different scenarios, each designed to trigger anger or frustration, and works out a way for the patient to respond appropriately in each case. The keys to successful generalization of these role-playing techniques to real-life situations after discharge are the amount of practice and the variety of scenarios the patient is exposed to while in treatment.
Woman who was diagnosed with FAS at 4 years of age, shown here at 9, 13 and 19 years. Her early facial manifestations of FAS have evolved into a fairly normal facial phenotype by adulthood, although she has remained growth deficient; IQ scores have been in the 85-90 range.
In addition to individual treatment of patients with FAS or FAE, another important aspect is family therapy. The ability of a patient to sustain progress made in treatment once he or she is discharged depends heavily on the amount of support available in the home environment. Consequently, involving the family in treatment at the outset is critical to ensure adequate understanding and support for continued behavior change following institutional discharge. At a minimum, the significant people in the patient's life need to be aware of behavioral rules or guidelines the individual has learned in treatment so appropriate feedback and positive reinforcement can be provided. If this is the first time that FAS/FAE has been suspected as an etiologic factor in the patient's disordered behavior, the family will need education and support concerning this issue as well.
A third element of inpatient programs that enhances treatment outcome is professional aftercare support. While supportive and knowledgeable family members (parents, spouse, significant other, etc.) are important, they are not always available or knowledgeable enough about community resources to be the sole source of external support. Patients with fetal alcohol impairment often need intensive case management if they do not have a supportive family member who can fill this role. It can be a complex task to coordinate the many services that the patient may need, such as ongoing individual (outpatient) therapy, vocational support/job coaching, housing, transport-ation and financial assistance. We find that, while patients with FAS/FAE often talk as though the resolution of these problems will be easy for them, in reality they are often unable to follow through in obtaining services on their own behalf. Memory problems, attentional problems and poor organizational skills make these patients dependent on a strong infrastructure in the aftercare phase of treatment.
Case management services can be obtained from private and state agencies that provide support for persons with developmental disabilities, if the individual qualifies for such services. While the patient is still in inpatient treatment, it is important for the discharge planning coordinator to initiate contact with appropriate agencies that have been identified as potential sources of support for the individual in the aftercare phase. Psychological testing, often a necessary criterion for disability eligibility, should be carried out early in the treatment program. Treating individuals impaired with FAS or FAE is not a straightforward process and little has been written about it. It would be well for facilities that accept such patients into their programs to be aware of the complex problems experienced by these patients and the intensive services they will require during their inpatient stays. Inservice training about FAS/FAE is a crucial step in increasing staff awareness. With proper planning and accommodations made for the specific needs of patients impaired by fetal alcohol exposure, treatment outcome can be positive.
References
Galanter, M., "Network Therapy for Alcohol and Drug Abuse: A New Approach in Practice," Basic Books (1993).
Streissguth, A.P., Little, R.E., "Unit 5: Alcohol, Pregnancy, and the Fetal Alcohol Syndrome: (Second Edition)," the Comprehensive slide Teaching Program for Biomedical Education developed by Project Cork of the Dartmouth Medical School. Milner Fenwick, (1994).
Natalie J. Novick
Dr. Novick is a clinical psychologist, sexual deviancy counselor and senior fellow at the Fetal Alcohol and Drug Unit, University of Washington Medical School at Seattle.
Ann P. Streissguth
Dr. Streissguth is the director of the Fetal Alcohol and Drug Unit and a professor in the Department of Psychiatry and Behavioral Sciences. (800/432-8433)