ATTC Messenger February 2015: Helping Clients with Cognitive Impairments
Screening and Modifications to Treatment: A New Approach to Helping Clients With Cognitive Impairments *
By The SAMHSA FASD Center for Excellence (FASD CFE)
Fetal Alcohol Spectrum Disorders (FASD) is a non-diagnostic umbrella term describing the range of effects that can occur in an individual whose mother consumed alcohol during pregnancy. Alcohol is a potent teratogen, meaning that it can permanently damage the developing fetus during pregnancy; it is, in fact, the leading preventable cause of developmental disabilities and birth defects.
Many people think that FASD only affects children; however, the effects of prenatal alcohol exposure are lifelong. Due to a lack of diagnostic capacity in the U.S. and internationally, symptoms of most individuals with this disorder remain undetected. They are often identified as being non-compliant and are not successful in typical treatment programs. However, with proper identification and modifications to treatment protocols, these individuals can achieve better recovery outcomes and quality of life.
FASD is the full range of effects of prenatal alcohol exposure, but specific diagnoses exist within the spectrum, including Fetal Alcohol Syndrome (FAS), partial FAS (pFAS), Alcohol-Related Neurodevelopmental Disorders (ARND), Alcohol-Related Birth Defects (ARBD) Encephalopathy/Alcohol-Exposed (SE/AE), and Neurobehavioral Disorder/Prenatal Alcohol Exposed (ND/PAE).
Only ND/PAE has been assigned a code (315.8) in the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5).
Prenatal alcohol exposure affects the developing brain of the fetus more than any other substance of abuse. The damage to the brain directly affects behavior. As a result, many people with an FASD demonstrate behaviors that appear to be willful. For instance, a person with an FASD may be given multiple directions, say they know what to do, and then not follow through. Although this can appear to be oppositional behavior, it is often due to damage in the part of the brain responsible for immediate or working memory. In addition, individuals with an FASD frequently have difficulty with verbal receptive language processing. As this is the basis of many treatment protocols (e.g., cognitive behavioral therapy, motivational interviewing), people with an unrecognized FASD will be seen as noncompliant, uncooperative, or unmotivated in treatment, and as a result may ‘fail’ or drop out.
The most recent estimates of the prevalence of the full spectrum of FASD in the general population are between 2 and 5 percent. In systems of care, including substance abuse treatment and recovery programs, prevalence may be higher, as co-occurring substance abuse or mental health issues are strongly associated with FASD. The Children’s Health Act of 2000 recognized FASD as a significant public health problem, leading SAMHSA to establish the FASD Center for Excellence in 2001 to raise FASD awareness and assist systems of care in integrating effective FASD prevention and treatment.
Over the last 14 years, the FASD CFE has produced over 100 original products for consumers and professionals, addressing all aspects of FASD and co-occurring life issues that frequently accompany these disorders. In collaboration with numerous experts and researchers, the FASD Center for Excellence developed Treatment Improvement Protocol (TIP) #58, Addressing Fetal Alcohol Spectrum Disorders. Released in early 2014, TIP 58 is the first entry in the TIP series to directly address FASD.
In addition, the FASD Center for Excellence provided more than 600 trainings between 2001 and 2013 to treatment programs and state and local agencies on effective methods for addressing FASD. The FASD Center for Excellence’s lead trainer for many years, Dan Dubovsky, M.S.W., is one of the co-authors of an emerging treatment model called Screening and Modifications to Treatment (SMT), which represents an important and new opportunity to improve recovery outcomes for individuals in substance abuse treatment who have unrecognized cognitive impairments caused by prenatal alcohol exposure.
Addressing the Need: Screening and Modifications to Treatment (SMT)
In most cases individuals with an FASD are not properly diagnosed, or if they are it is as a child or adolescent, not as an adult. Although the Centers for Disease Control and Prevention (CDC) have suggested screening criteria for referring children for full FASD assessment, screening for adults has not been available. However, research has described a mix of primary cognitive and neurodevelopmental deficits (e.g., memory, attention, executive function, adaptive behavior), along with associated disabilities and related issues that could potentially be mitigated by treatment (e.g., easily victimized, unfocused and distractible, difficulty handling money, trouble understanding consequences and learning from experience, problems perceiving social cues, poor frustration tolerance, inappropriate sexual behavior, mental health problems, trouble with the law).
Based on repeated requests from substance abuse treatment centers for a method for identifying adults with a possible FASD and more effectively serving them, Mr. Dubovsky, Dr. Therese Grant, and other researchers at the University of Washington have developed the SMT approach, a key part of which is the Life History Screen (LHS). The items on the LHS are a combination of 11 items already asked in the Addiction Severity Index (ASI), along with questions not typically asked at intake. Even if these questions have been asked in a program’s intake process, they are not generally asked through the lens of a possible FASD. The LHS acts as the basis for the SMT approach; for clients who screen positive utilizing the LHS, discussions are held by treatment staff regarding what modifications to treatment should be made to enhance outcomes.
The LHS is designed as a structured screening instrument that can be embedded within a treatment program’s existing intake interview protocol and administered by service providers and clinicians to clients who have completed detoxification and are entering, or in, treatment. The LHS requires approximately 15 minutes to administer, and should be introduced as early as possible in the treatment process so that strategies may be implemented that will help avoid treatment failure. However, some of the questions are best asked once a trusting relationship has been established with the individual. Based upon self-report with explanations of the questions when necessary, LHS questions are framed within the context of a client’s customary behavior. Thus, in the case of clients presenting for substance abuse treatment, ‘customary’ would not include behaviors that only manifest while under the influence of alcohol or drugs.
Although clinicians may have reservations about asking clients to divulge personal information and family history, fearing that such probing may be too intrusive and might negatively impact the therapeutic relationship, researchers have found that when the need for such questioning is explained non-judgmentally and with compassion, clients usually respond positively and candidly. For agencies looking to implement SMT, the suggested modifications can be presented via trainings to staff members, and are based on the clinical experience of SMT developers and information published in the Journal of Addiction Medicine.
Third Thursday iTraining, February, 2015: Learn More About SMT!
For February’s Third Thursday iTraining, we will take a closer look at SMT and how it can possibly help your agency or program achieve better treatment outcomes. Presented in partnership with the FASD Center for Excellence, the iTraining will feature Mr. Dubovsky, who will provide a more in-depth look at SMT, including the origins of the model, some typical modifications, training of staff, and keys to implementation and sustainability. As always, there will also be a Q&A session at the end of the training.
We hope you will join us for this free event, scheduled for Thursday, February 19, 2015, from 2:00pm to 3:30pm (EST). Click here to register and learn more.