Identifying Clients With Possible

Fetal Alcohol Syndrome

Fetal Alcohol Effects in the Treatment Setting

by Natalie J. Novick, Ph.D. and Ann Streissguth, Ph.D.

This is the first of a two-part series on identifying and effectively treating people with FAS/FAE in treatment programs. Part two appears in Treatment Today Winter 1996, Vol.7, No.4, p.20.

Why do even the most effective, well-run programs have treatment failures with motivated patients? One reason may be due to a problem that is sometimes difficult to see: organic brain damage. People with central nervous system (CNS) dysfunction have difficulty processing information, which can have a significant impact on how they respond to treatment. Such individuals may appear normal during routine assessment, but once they begin participating in treatment, difficulties soon become apparent that set them apart from other patients. In particular, there may be problems linking cause with effect, memory deficits, or inability to think in abstract terms -- all of which are important for treatment efficacy. If a program's resources are to appropriately address the issues of such patients, CNS dysfunction must be addressed at intake, and services must be tailored to meet special needs.

One cause of CNS dysfunction is prenatal exposure to alcohol, estimated to affect approximately one to three per 1000 people in the United States.

(FAS) manifests in three primary symptom categories:

• Growth deficiency of prenatal onset (height or weight);
  
• Central nervous system (CNS) dysfunction, including microcephaly, delayed development, hyperactivity, attention deficits, learning disabilities and intellectual deficits; and
  
• A specific pattern of facial characteristics, including short palpebral fissures, thin upper lip and smooth and/or long philtrum. Individuals who are exposed to alcohol in utero and who display some, but not all, of these characteristics are often described ashaving possible fetal alcohol effects (FAE). The CNS dysfunction associated with FAS/FAE frequently causes attention problems, memory problems, affective problems and maladaptive behaviors such as poor impulse control.

Unless an individual exhibits the specific facial features and growth problems associated with prenatal alcohol exposure, it is often difficult to diagnose the disorder. Quite often, by adulthood, the normal maturation process has attenuated the characteristic facial features and growth anomalies. Consequently, only the cognitive and behavioral manifestations of FAS/FAE are left to serve as markers for the disorder. This situation not only makes diagnosis difficult, it seriously complicates treatment for impaired clients. Assessment procedures often address intellectual capacity, which can be determined by means of IQ testing. But assessing behavior is more complicated and more time consuming. However, if patients with FAS/FAE go unrecognized, treatment failure is almost certainly guaranteed. Such patients cannot deal easily with the concepts and abstractions that typically comprise most programs and often have difficulty following through on basic rules (e.g., abstinence) that are far more concrete.

How does the treatment provider recognize the patient with FAS/FAE and address his or her special needs?

The place to begin is the intake process. As part of the medical examination, ask:

• Have you ever been diagnosed with FAS/FAE or suspected to have FAS/FAE?
• Did your biological mother have a drinking problem? If yes, did she have these problems as far back as you can remember?
• Did your biological mother drink during pregnancy?
• Have you ever had seizures or convulsions (often a symptom of organic brain disorder)?
• Did you have learning problems in school?
• Were you ever diagnosed, or thought to have, attention deficit disorder (ADD) or hyperactivity as a child? (Although not all attention deficits are caused by prenatal alcohol exposure, these conditions can be behavioral markers or FAS/FAE.)

In the behavioral history, assess such factors as vocational history, social history, relationship history, legal history and, of course, alcohol and drug use history. While many of these domains are typically addressed in the intake interview, it is unusual for treatment programs to include specific questions that target FAS/FAE behaviors. For example, it is common for individuals with FAS/FAE to have vocational problems. Ask whether the patient has ever had difficulty getting hired for or holding a job, required ongoing workplace supervision, exhibited unreliable work behavior (e.g., tardiness, missing days of work, etc.) or inappropriate anger in the workplace, had problems with supervisors or with other employees or had difficulties with the cognitive demands of a position.

Streissguth, A.P., and Little, R.E., "Alcohol, Pregnancy, and the Fetal Alcohol Syndrome," 2nd Edition. Unit 5 of "Alcohol Use and Its Medical Consequences. A Comprehensive Slide Teaching Program for Biomedical Education." Developed by Project Cash of the Dartmouth Medical School. Available from Milner-Fenwick, Inc., Timonium, MI. (800/432-8433). Click here for enlarged image.

If your program does not routinely test IQ at intake, consider adding this element to your process.

Also ask:

• Did you graduate from high school? If not, why not?
• Did you ever receive special services in school? (e.g., special education classes, tutoring)
• Did you ever repeat a grade?
• Did you ever have a problem with school truancy?
• Were you ever suspended or expelled?

With regard to social history, ask whether the patient feels lonely or left out of social groups, prefers friends who are younger or older than himself/herself or feels taken advantage of by others. Individuals with FAS/FAE typically make friends readily but often find it difficult to keep them. Social groups may find the behavior of people with FAS/FAE "strange" and con-sequently, either exclude such individuals or take advantage of them.

The purpose of identifying patients with suspected FAS/FAE at intake is three-fold:

• Pursue a more definitive diagnosis, if possible, within the community.
  
• Make the best possible use of treatment programming.
  
• Develop an effective advocacy network in the aftercare phase to address long-term, post-treatment needs.

Without targeted assessment and appropriate accommodation for the special needs of individuals impaired by prenatal alcohol exposure, treatment -- no matter how effective -- is likely to fail.

Natalie Novick

Dr. Novick is a clinical psychologist and sexual deviancy counselor who is senior fellow at the Fetal Alcohol and Drug Unit.

Ann Streissguth

Dr. Streissguth is the director of the Fetal Alcohol and Drug Unit and a professor in the Department of Psychiatry and Behavioral Sciences, University of Washington Medical School at Seattle.