Mental Health Treatment Strategies That Work

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Mental Health Treatment Strategies That Work
Building FASD State Systems Meeting San
Francisco, CA May 10, 2006 Therese Grant, Ph.D.
University of Washington Fetal Alcohol and
Drug Unit Parent-Child Assistance Program
(PCAP) 180 Nickerson, Suite 309 Seattle,
Washington 98109 [phone]
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Limited research available on effective FASD
interventions

• Premji et al., (2004) reviewed the literature on
  FASD interventions with youth
• 10 studies found of 7 reviewed
• 2 medication trials
• 1 cognitive control study
• 1 supplementary reading program
• 1 tutoring program
• 1 functional analysis study
• 1 multisystems collaborative community based
  intervention

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With no mental health intervention studies to
draw on What to Do?

• Look to
• Clinical data from professionals, teachers, and
  parents who have seen positive changes using an
  intervention.
• Practices shown to be effective with other
  disorders that are being adapted for those with
  FASD (e.g., ADD).

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Theres no cookbook solution for FASD intervention

• One-size doesnt fit all
• - Each individual has a different
  neuropsychological profile (depending on timing
  and dosage of prenatal alcohol exposure).
• - Variability is the hallmark of FASD (within
  individuals AND between individuals).

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A source of FASD mental health problems organic
brain damage associated with prenatal alcohol
exposure

• The primary disability of FASD is permanent brain
  damage, manifest as neuropsychological deficits
  and neurobehavioral problems.

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FASD Neurobehavioral Disability

• Neuropsychological deficits do not go away.
• They impact the individuals ability to
  participate in interventions because of problems
  with
• Executive functioning
• (sequencing of behavior, cognitive flexibility,
  response inhibition, planning, organization of
  behavior)
• Attention
• Memory
• Hypersensitivity to sensory stimulation
• Impulsivity
• Receptive language

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Strategy Direct Therapeutic Intervention

• Treat primary mental health problems (e.g.,
  depression, anxiety disorder) with interventions
  adapted to the individuals neuropsychological
  and health profile.

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Strategy Direct Therapeutic Intervention

• PRINCIPLES
• Accommodation vs. Cure Cant cure the existing
  brain damage
• Change the environment, not the person (physical
  environment, attitudes)
• Individualize Base intervention on the persons
  unique neuropsychological and health profile
• Adapt interventions Alter existing
  interventions based on individuals learning
  style, memory problems, attention deficits, etc.
  
• Maintain intervention Consistency
• Involve others

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A Second Source of Mental Health Problems

• Distress caused when a person with FASD does not
  receive appropriate support to address their
  neurobehavioral deficits, leading to chronic
  failure, loss, frustration, victimization
  (secondary mental health problems).

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Strategy Comprehensive Prevention Intervention

• Provide sustained, comprehensive, multi-systemic
  and developmentally appropriate support to the
  individual with FASD.

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Strategy Comprehensive Prevention Intervention

• PRINCIPLES
• Multi-systemic (medical care mental health
  school social service vocational training
  agency social services family church)
• Multi-modal (individual therapy family therapy
  medication vocational training/job coaching
  case management support groups)
• Individualized (based on comprehensive
  assessment)
• Life-span perspective (sustain the support)
• Family-based (involve caregivers/advocates)

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Mental Health

• Psychotherapy focusing on concrete issues (e.g.,
  anger management social skills coping with
  depression)
• Therapy should also address the emotional pain of
  being different, having a disability
• Refer to support groups for individuals with FASD
  and their families
• Refer for family therapy
• Respite care for family members to prevent
  burnout and development of stress-related health
  problems

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Mental Health

• Traditional talk therapy is not helpful due to
  the language, memory, and attention problems
  typical of individuals with FASD
• BUT, psychotherapy, adapted to the individuals
  learning style (i.e., multi-sensory vs. only
  auditory-verbal role playing use of art) can be
  very beneficial
• Requires creativity, persistence, clinical
  intuition on the part of the therapist
• Involve patient in the process (learning style
  cultural sensitivity)

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Mental Health

• Carefully monitor suicidal ideation
• Individuals with FASD _at_ risk for suicide
• Considerable overlap between the risk factors for
  suicide and the clinical profile of FASD (e.g.,
  impulsivity co-occurring mood disorder
  substance abuse problems)
• Also vulnerable due to job loss, relational
  loss, social isolation

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Mental Health

• Psychiatric medication
• Medication management is complex
• organic brain damage (structural and/or
  neurochemical)
• alcohol-related birth defects (e.g., liver)
  affect metabolism of medication
• presence of multiple co-morbid conditions
• Risk overmedication negative side effects
• Benefit control symptoms allow individual to
  participate in interventions

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Social Relationships

• Arrange recreational activities that provide safe
  social contacts and friendships
• Provide ongoing education regarding appropriate
  sexual behavior and how to protect against
  victimization
• Monitor social relationships and use of leisure
  time
• Teach friendship skills

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Financial

• Guardianship of funds may be required or a
  protective payee
• Individual should be raised with the idea that
  he/she will need help managing money
• Monitoring finances to ensure individual is
  living within means and not being financially
  victimized

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Vocational

• Specialized job training
• Sheltered employment
• Long-term job coaching/training
• Special focus on social aspects of work (getting
  along with co-workers inappropriate vs.
  appropriate behavior at work)

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Physical Health

• Regular primary health care
• Specialty care if there are ARBDs affecting
  kidney, liver or heart
• Ongoing education regarding appropriate family
  planning
• Focus on the more reliable methods of family
  planning (e.g., IUD)

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Housing

• Residential placement may be necessary
• In-home support for those able to live
  independently
• Ongoing supervision and monitoring to ensure
  safety

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FASCETS Oregon Fetal Alcohol Project

• Three-year study examining the efficacy of
  interventions that addressed the neurocognitive
  issues of FASD
• Trained multidisciplinary/multi-systemic teams
  who worked with children/adolescents (ages 3-14)
• Pretest-posttest results (N19)
• Reduced irritability, disruptiveness, anger,
  aggression, and depression in the children and
  adolescents
• Reduced levels of stress in adult caregivers
• Improved self-efficacy in parents and
  professionals (Malbin, 2006)

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• Diane Malbin
• FASCETS (Fetal Alcohol Syndrome Consultation
  Education and Training Services, Inc.)
• P.O. Box 83175
• Portland, Oregon  97283
• Phone/Fax  [phone]
• www.fascets.org
• dmalbin_at_fascets.org
•  

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Parent Child Assistance Program Double Jeopardy
Project
PCAP An intensive, 3-year advocacy/case
management intervention serving high-risk alcohol
and/or drug abusing mothers. Double Jeopardy
One-year project funded by the March of Dimes to
assist women in PCAP with FASD and develop a
community service training model Grant, T.,
Huggins, J., Connor, P., Streissguth, A.
(2005) Grant, T., Huggins, J., Connor, P.,
Pedersen, J., Whitney, N., Streissguth, A.
(2004)
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Components of PCAP Relevant for Individuals with
FASD

• Each mother paired with an advocate for 3 years
• Advocate develops and coordinates a network of
  contacts with family, friends, and providers
• Advocate links client with appropriate community
  services and/or providers and coordinates this
  service network
• Individualized service plan
• Advocates also provide advocacy for other family
  members as needed

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Psychosocial Profile PCAP FASD Clients (N19)
Average age 22 Years (Range 14-36) Mostly
white (60), unmarried (85), and poorly
educated (45) Troubled life history profile
Family history drug/alcohol abuse (100)
Sexual abuse (79) Physical abuse (84)
Unstable and disrupted care giving (100) High
levels of psychiatric distress and behavioral
problems Poor quality of life relative to other
at-risk populations
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Advocates ExperienceShe just doesnt get it!

• The impact of neuropsychological deficits was
  obvious.
• Advocates had to modify their usual approaches.
• Clients were often unable to learn new skills
  or learned them very slowly.

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Role of Advocate

• Implemented an intervention plan appropriate
  for an FASD client
• Helped providers understand the relationship
  between organic brain damage and the FASD
  clients behavior
• Reinforced use of clinical management
  strategies

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Strategies When TreatingClients with FASD

• Use short sentences, concrete examples, and avoid
  analogies
• Present information using multiple modes
• Simple step-by-step instructions (written and/or
  with pictures)
• Role-playing
• Ask patient to demonstrate skills (dont rely
  solely on verbal responses)
• Revisit important points during each session

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Strategies When TreatingIndividuals with FASD

• Teach generalization (dont assume it will occur)
  
• Help client identify physical releases when
  escalating emotions become overwhelming
• Be alert for changes/transitionsmonitor more
  carefully, do advance problem-solving

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• "I thought I was weird. I thought I didn't
  belong here. And then when I talked to (PCAP
  advocate), it was like wow! You know what Im
  talking about!
• - A PCAP Client with FASD

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Community Service Providers What We Found

• Providers knew very little about FASD.
• Providers had limited direct experience with
  this population.
• Few services were suited for individuals with
  FASD.
• Obtaining a diagnosis in adulthood was
  difficult.
• Even for experienced PCAP advocates, working
  with an FASD client was more difficult than
  working with a typical PCAP client.

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Educating Providers

• We identified key providers interested in the
  problem, and willing to work with a PCAP client
  with FASD
• We provided FASD education, a PCAP case
  manager, and back-up consultation as problems
  arose
• Education hands-on experience FASD
  demystified
• Providers learned to deliver services
  appropriately tailored to specific needs of
  FASD patients.

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12-month Outcomes
16/19 were receiving medical /or mental health
care 14/19 were abstinent from both drugs and
alcohol (11 maintained abstinence 3 newly in
recovery) 5/19 were still using drugs/alcohol
but 3 of these 5 were using reliable birth
control methods (2 tubal ligations, 1 Depo
Provera). 14/19 were using contraception
regularly (Depo 7 Tubal 3 IUD 2
OCPs 2) 16/19 obtained stable housing
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Reflection on Outcomes

• Result We connected clients to providers and
  educated providers about FASD
• Problem People with FASD require coordinated
  services throughout the lifespan
• Conclusion Need a FAS Advocate program (FASA)
  modeled after PCAP that provides longer-term
  advocacy to help clients and families navigate
  complex community systems of care

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Conclusion Need for FAS Advocate program (FASA)
modeled after PCAP that provides longer-term
advocacy

• Well-trained advocate assigned to an FASD client
  and his/her family
• Link client with community services and
  providers
• Help client and family navigate complex community
  systems of care
• Advocate supported by intensive training,
  supervision, and peer support