PRESENTORS David Gerry, BSc - NAADAC · David Gerry, BSc LivingWithFASD.com Diane Malbin, MSW ... David Gerry, BSc LivingWithFASD.com Trying Differently Rather Than …

Diane Malbin, MSW FASCETS.org

David Gerry, BSc LivingWithFASD.com



Trying Differently Rather Than Harder: Improving Treatment Outcomes by Accommodating Brain Based Conditions like FASD

PRESENTORS

Seattle, WA September 26 - October 1, 2014


David Gerry, BSc LivingWithFASD.com David Gerry, BSc LivingWithFASD.com

David Gerry, BSc

Why Brain Based Conditions like FASD Are Important in Addiction Programs and Practices



US Statistics 2012

õ Number of births 3,952,841 (2012)

õ FASD Prevalence rate 2-5% (May 2009) year = õ About 80,000 – 198,000 babies/year born

prenatally exposed õ 51% of pregnancies unplanned (40-60% differs

state by state) õ NIAAA 2012 survey – 71% people drank in past

year 57% in the past month õ About 50% of 2.6m/yr complete treatment

(SAMSHA 2012)



ALCOHOL STATS AROUND THE WORLD – W.H.O. 2010

õ Belarus –17.5 litres pure alcohol õ Ireland –11.9 litres õUK – 10.39 litres õUS – 8.51 litres (43rd) õ Canada – 8.26 litres (45th)



Prevalence of Alcohol Use During Pregnancy in US

õ 7.61% of women drink during pregnancy

õ 1.41% of women binge during pregnancy

Binge drinking rates have not changed

significantly since 1991 (Floyd & Sidhu, 2004)

õ 1CDC 2010



Embryonic Development & Risk





IQ vs Adaptive Functioning



Choline and the Brain

õ Choline is a dietary nutrient important for all cells to function normally. Choline is required for synthesis of essential components of membranes and is an important building block for neurochemicals in the brain.

õ Sources include many proteins like meat, fish, cheese, nuts avocado etc



Choline and the Brain



Level of Activation in Dorsolateral Prefrontal

Cortex

Number of Correct Responses on N-Back

Key: 1-Back (simple task)

2-Back (difficult

task)



Client Demographics õAge: 19 years to 45 years õ Ethnicity: 9 Caucasian, 10 First Nations

or Métis, 1 Afro-Caribbean õMarital Status: 17 single, 3 common

law, only 1 had been married õ Living Situation: 12 alone, 3 with

relatives, 3 with partner, 2 in FASD Action funded

collaborative homes õ Employment: 1 had a part-time job

12



Birth Mothers’ Histories

0102030405060708090

100

ResidSchool

Dead DV Alc/Fam MH Homeless Specneeds

13



Clients’ Trauma Histories

0102030405060708090

100

Poverty DV PatETOH

FH Legal MomDead

SexTrade



28 Children of 12/20 Clients

0102030405060708090

100

FASD confirmedETOH

Behav Dev delay Normal # in Care



Clinic Results: Mental Health

0102030405060708090

100

AnyMHA

DEP Adhd Mood Ptsd Anx Ld



Video clip of the experience of the effect of receiving an FASD Diagnosis as an adult.



Psychiatric Training in Fetal Alcohol Spectrum Disorders "Inadequate"

õ http://www.medscape.com/viewarticle/711792 õ 2009 survey with 308 respondents of recent psych. grads õ 40% of respondents reported receiving supervision with a

patient with suspected or confirmed FASDs, õ 70% reported never diagnosing a patient with an FASD, õ 51% reported they had never treated a patient with the

condition. õ 83% reported they had never used any standardized

diagnostic schema at all. õ many respondents mistakenly reported that "it is safe to

drink some alcohol" during the first (6%), second (15%), and third trimesters (30%).

http://www.medscape.com/viewarticle/711792



DSM-5 AND FASD (R.Densmore 2014)

õ P 86,“Other Specified” Neurodevelopmental Disorder e.g. “Neurodevelopmental disorder associated with prenatal alcohol exposure.”

õ P 783, “Conditions for further study” e.g. “Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure (ND-PAE).”

õ P 52, DSM-5 actually encourages definition of severity levels of symptoms and how much support is required e.g. Autism

õ - “ADHD is the most frequent presentation of FASD....FASD’s are true clinical masqueraders and ADHD is their most likely disguise!” (O’Malley, 2007)



Model of Prenatal Alcohol Exposure

Alcohol Pair-fed Control • Liquid diet, 36% calories derived from ethanol

• Nutritional control group

• Control for reduced food intake in Alcohol-consuming females

• Pelleted control diet, fed ad libitum

Pregnant female rats, placed on diet throughout pregnancy Kasia Stepien



Pregnant Sprague-Dawley dams, placed on diet throughout gestation:

Ethanol Pair-fed Control

Model of Prenatal Alcohol Exposure

Assess offspring:

Kasia Stepien



Prenatal alcohol exposure increases locomotor (typical) response to amphetamine

Uban et al, 2014, under review



Figure 1. Diagram describing the spiralling distress/addiction cycle from a psychiatric perspective with the different criteria for substance dependence from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, incorporated at different stages. There are three major components of the addiction cycle: preoccupation-anticipation, binge-intoxication, and withdrawal-negative affect. (Koob & LeMoal, Neuropsychopharamacology, 2001)



Changes in the brain (neuroadaptation) result in increased value of drug, decreased executive function, decreased reward,

increased stress " transition to addiction Neuropsychopharmacology (2014) 39, 254-262



1Washington State Parent Child Assistance Program 2Grant et. al. International Journal of Alcohol and Drug Research 2014

Outcomes for Substance Abuse Treatment Programs For Women in PCAP1 1997-2011, Adapted from Grant2



Prenatal alcohol exposure & addiction treatment (Grant et al., Addict Med, 2013 – see Table 1)

FASD characteristic Treatment recommendation Difficulties with executive function

Teach how to set appointment reminders on his/her cell.

Concrete- Black or White Thinker

Avoid metaphors, if joking indicate.

Impaired verbal receptive language processing

Remember he/she often express themselves at a much higher level than they understand.

Social impairments Frame treatment expectations & group participation with perspective that coping capacity and interpersonal skills likely much younger than chronological age.



Summary I õ FASD is a VERY common, invisible brain

based disability, 2-5% of the population. õ 46% of people with a diagnosis of FASD had

alcohol or drug problems õ Laboratory studies show paradoxical or

opposite effects when FASD is a factor in prolonged drug sensitivity.

õ Adaptive Functioning level is a better predictor that IQ for treatment outcomes



Summary II õHave protein (choline) rich foods and snacks

readily available. õ Inclusion of FASD in DSM V as an appendix

means that many are still very tentative about the extend and breadth of the challenge

õ For more details, please see the NAADAC journal article (Fall 2014) titled “Does your Program or Practice Help….”

FOR MORE INFORMATION: Download new free FASD Life History Screening Tool &

1 hour training with Dr. Joanne Weinberg: http://LivingWithFASD.com/addiction/



Diane V. Malbin, MSW

Fetal Alcohol/Neurobehavioral conditions: FA/NB Practical Ways We Can We Adapt Treatment Programs to Support People with Brain Based Conditions Like FASD



From research to application

Or, What’s the brain got to do with it?

--Thank you, Tina Turner



Is FA/NB a physical disability? 1. Alcohol, drugs and other teratogens kill cells,

including cells in the brain 2. These causes changes in the physical

structure, neurochemistry in the brain 3. FA/NB is usually invisible, therefore 4. FA/NB is a brain-based physical disability;

behaviors are often the only symptoms



If FA/NB is an invisible physical disability

Then Providing accommodations for people with FA/NB is as appropriate, effective, and ethical as providing accommodations for people with other physical disabilities.





Examples of success

Artist, musician Warehouse person Electrician Boat builder Mechanic Child care worker Animal rescue worker Drummer, dancer BA, BS, MSW, PhD

Office worker Special ed. teacher Addictions counselor Massage therapist Truck driver Husband, wife: Parents Delivery person Parent Adult care worker



Layers of relevance

õ Policy, accreditation õ Program design, practice õ Personal õ Professional õ Friends õ Family members õ Self õ Children, grandchildren



FASCETS Neurobehavioral screening tool



Definition: Primary neurobehavioral characteristics

Behavioral symptoms of brain structure, function and dysfunction, including strengths.

Adapted from Streissguth, 1996



Primary symptoms 1.Developmental level of functioning 2.Sensory systems 3.Nutrition 4.Language and communication 5.Processing pace: How fast the brain works 6.Learning and memory 7.Abstract thinking 8.Executive functioning 9.Strengths



Uneven development adult

Actual age of person: 25 Developmental age--------13 Strengths (art, sports)--------------------------------28 Expressive language--------------------------26 Receptive language---11 Reading ----------------------------18 Comprehension ------12



Primary: Learning strengths

õ Relational: 1:1 õ Visual õ Auditory õHands-on õ Kinesthetic -- see, touch, move õ Experiential -- learns by doing õMultimodal -- uses all senses



Definition: Secondary behavioral symptoms

Secondary defensive behaviors develop over time when there is a “poor fit”

Defensive behaviors are normal reactions to

pain and are preventable.

Source: Ann Streissguth, 1996



Anonymous, with permission



Secondary behavioral symptoms 1. Fatigued 2. Frustrated 3. Anxious 4. Angry 5. Shut down, avoidant, blaming 6. Poor self esteem 7. Isolated 8. Depressed



Organized, efficient less energy required for task

Conner, et al 2005

PET Scans: The better the brain is organized, the less energy is required to do the task



Organized, efficient FAS: Disorganized, less less energy required for task efficient, more energy

Conner, et al 2005

PET Scans: The greater the disorganization, the harder the entire brain works, causing fatigue and irritability



Definition: Tertiary characteristics formerly known as “Secondary Disabilities”

are the net effect of chronic exhaustion, failure and frustration and are also

preventable



Tertiary characteristics / problems Trouble at home Trouble at school, dropout Social Services involvement Alcohol / drug-related problems / addictions Justice system involvement



Poor fit FA/NB Visual learner………........ Slower processing…….. Needs simplicity………... Difficulty organizing…… Concrete…………….........

Technique Verbal instruction Fast paced Complex Requires organizing Abstract



Good fit FA/NB Visual learner………........ Slower processing……… Needs simplicity………... Difficulty organizing……. Concrete…………….........

Technique Visual cues Slow down, fewer words One or two steps Provide support Hands-on, experiential



The Brain - Addiction link Olds and Milner, 1954 Identified the mesodopaminergic limbic

system (brain stem) as being involved in addictive processes



ASAM Public Policy Statement of Addiction August 15, 2011

Short Definition of Addiction: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry….

American Society of Addiction Medicine

Or, it is a brain-based condition with behavioral symptoms



Curious parallel

õ Research: Addictions are brain-based

õ Research: FASD is a Neurobehavioral condition õHow is this reflected in understanding and

practice?



Why don’t good techniques work?

What does the brain have to be able to do in order for strategies to work?



What does the brain have to be able to do in order for strategies to work? Example: Talking

Brain function required: Store information / memory Retrieve information…………… Make links…………………………… Abstract……………………….……… Generalize…………………………… Predict………………………………... Process quickly……………….…

Research on FA/NB has found brain differences: Difficulty with memory Difficulty retrieving information Difficulty forming links Concrete Difficulty generalizing Difficulty predicting Processes slowly



Remember the Streissguth study? Disabilities: FAS FASD Substance Abuse 21% 32% Mental Health problems 91% 94% School Problems 40% 63% Trouble with the law 51% 68% Homelessness 16% 30% Threatening or violent behaviors 35% 50% One or more 74% 93% Source: Streissguth, et al Secondary Disabilities Study, 1996



Secondary Disabilities study õNatural history design õ All subjects diagnosed FAS / FASD õ All continued to receive standard services

Power of this study is implicit: High rate does not mean problems are inevitable. It captures the limits of the current paradigm to achieve improved outcomes



Application: Functional Neurobehavioral Assessment

A systematic approach to developing person-specific accommodations in all

settings and managing the complexity of FA/NB



Application: Functional Neurobehavioral Assessment Setting: _Addictions tx__ Age: _32_ Developmental age: 15_ 1 Task or Expectation

2 Brain has to

3 Primary symptoms FA/NB

4 Devel. Age (est.)

5 Secondary behaviors

5 Strengths

6 Accommodations



Application: Functional Neurobehavioral Assessment Setting:_Addictions tx_ Age: 32_ Developmental age: 15 1 Task or Expectation

2 Brain has to


4 Devel. Age (estimate)


5 Strengths

6 Accommodations

Cognitive behavioral technique (language)



Application: Functional Neurobehavioral Assessment Setting:_Addictions tx Age: 32_ Developmental age: 15

1 Task or Expectation

2 Brain has to




5 Strengths

6 Accommodations


Analyze abstract



Application: Functional Neurobehavioral Assessment Setting:_Addictions tx Age: 32_ Developmental age: 15 1 Task or Expectation

2 Brain has to




5 Strengths

6 Accommodations


Analyze abstract

Concrete Literal




2 Brain has to




5 Strengths

6 Accommodations


Analyze abstract

Concrete Literal

14




2 Brain has to




5 Strengths

6 Accommodations


Analyze abstract

Concrete Literal

14 May not finish tasks, argues




2 Brain has to




5 Strengths

6 Accommodations


Analyze abstract

Concrete Literal


Artistic Hands-on learner




2 Brain has to




5 Strengths

6 Accommodations


Analyze abstract

Concrete Literal


Artistic Hands-on learner

Art, drama, music, relationship, role modeling



Application: Functional Neurobehavioral Assessment Setting: Addictions tx Age: _32_ Developmental age: 15


2 Brain has to




5 Strengths

6 Accommodations


Abstract, analyze

Concrete, literal


Artistic, hands-on learner

Art, drama, music, relationship, role modeling

Communicate

Process language

Slow processing pace

12 Anger, frustration

Determinedcreative

Art, drama, music, poetry



Application: Functional Neurobehavioral Assessment Setting: Addictions tx Age: 32 Developmental age: 15


2 Brain has to




5 Strengths

6 Accommodations


Abstract, analyze

Concrete, literal


Artistic, hands-on learner

Art, videos, relationship, role modeling

Communicate

Process language

Slow processing pace

12 Anger, frustration

Determinedcreative

Art, drama, music, poetry

Apply new knowledge

Store, retrieve and generalize

Memory problems, difficulty generalizing

16 Defensive Relational Teach in different settings, use mentor



Addictions treatment? õ Cognitive-behavioral? õ Language based? õ Require the ability to reflect, recall,

analyze, integrate, reframe and generalize?

õ Post-tx require the ability to organize, plan, initiate, prioritize, inhibit impulses?



Treatment opportunities 1. Intake, history, neurobehavioral screen 2. Identify strengths, challenges 3. Simplify. Adapt treatment plans

1. Fewer objectives 2. Fewer words 3. More concrete, visual, relational

4. Educate client, family, sponsor



Questions?

David Gerry, BSc Diane V. Malbin, MSW

LivingWithFASD.com FASCETS.org

Phone: (250) 889-1429 PO Box 69242

Portland, Oregon 97239 Phone/FAX: (503) 621-1271

[email protected] [email protected]

FOR MORE INFORMATION: Download new free

FASD Life History Screening Tool & 1 hour training w/ Dr. Joanne Weinberg: http://LivingWithFASD.com/addiction/

Documents

PRESENTORS David Gerry, BSc - NAADAC · David Gerry, BSc LivingWithFASD.com Diane Malbin, MSW ... David Gerry, BSc LivingWithFASD.com Trying Differently Rather Than …