FAS and Mental Health Services: A Therapist's Perspective
by Kenneth Dunning, M.S., C.M.H.C., N.C.C.

Children with disabilities from prenatal alcohol exposure present a
significant and inescapable challenge to the Mental Health community.

     1. Significant, because when FAS/E is present it is a
     pervasive factor in all the behavior presentations of the
     affected client.

     2. Inescapable, because failure to recognize and ‘factor’
     FAS/E into any planned intervention is to diminish, if not
     eliminate, the chances of success. A lot of  effort and
     resources will be wasted and client, family and treatment
     provider will all be closer to burn out.

So how do we, as treatment providers, effectively screen, diagnose and
plan for individuals with FAS/E?

Screening & Diagnosis
 This stage is difficult because FAS/E is not in the current American
Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders (DSM IV). But to try conventional, cognitively-based
interventions alone, for any standard presenting diagnosis, is like
trying to stop a client from sneezing, while ignoring pneumonia. Alcohol
Induced Persisting Dementia is a diagnosis in the DSM IV which I believe
accurately describes the phenomenon of FAS/E. But I have never seen it
used in that manner.  I have considered using it because the public’s
familiarity with dementia would give them a reference point as to the
seriousness and impact of FAS/E.

So the lack of an  FAS/E diagnosis in the DSM IV means mental health
professionals have to rely on personal experience for screening. I have
established a method which works for my clients and their families. I
usually find myself alerted to the possibility of FAS/E if a client has
a long standing history of developmental and/or behavioral problems that
seem pervasive and elusive.  When interventions that really should work,
don’t, I get a history on the mother’s (and father’s) alcohol
consumption. I include the father because if the father drank a lot and
the mother claims no alcohol consumption, that may be a clue that the
mother is inaccurately reporting her drinking behavior.  (Also we are
still learning more about what the father’s alcohol consumption means
for the child.) By current standards, if there was no maternal alcohol
consumption, it can’t be FAS/E. If there was maternal consumption, and
the behavioral symptoms are consistent with FAS/E, then I begin the
process of getting the client evaluated at the University of
Washington’s FAS/E Diagnostic Clinic.  If FAS/E is present, the client
may be eligible for needed benefits and services through Social
Security/SSI  and/or the Washington State Division of Developmental
Disabilities. Having a thorough and authoritative diagnostic workup,
such as the ones given at the University, can be beneficial in
substantiating the disabilities and proving eligibility.

FAS/E is not uncommon in clients receiving mental health care. My own
experience over the past 4-5 years is that 2-4 out of 10 of my clients
at any given time have a behavioral profile and history consistent with
FAS/E.  We, as mental health providers, need to be aware and informed
about this disability.

In the area of case planning, I have found a diagnosis very important.
By the time a child with FAS/E (diagnosed or not) comes to the attention
of a mental health provider, the parents are usually exhausted and
multi-stressed. This means the professional is presented with parents
who typically look upset, angry, intolerant and who may have attempted,
in desperation, some parenting techniques which can appear less than
admirable. This seems to be a real 'trigger’ for a lot of mental health
providers, which can cause a rush of support for the apparently poor,
misunderstood child and a concurrent rush to judgment of the parents.
Parents report this to be a common error that can have counterproductive
results. Therapists alienate the parents and consequently hinder the
chances of forming an effective team.

After eliminating or confirming an FAS/E diagnosis, the mental health
professional should then look at the possibility of other co-existing
conditions. There have been some DSM diagnoses which are commonly
identified in children with FAS/E, according to the information gathered
by FAS Family Resource Institute. These include: Oppositional Defiant
Disorder, Conduct Disorder, Attachment Disorder, Attention Deficit
Hyperactivity Disorder, Depression, Post Traumatic Stress Disorder, and
Learning Disorders, among others. Once all the conditions are
identified, the therapist can turn to the next stage.

Planning  and Treatment
What has been shown to be of value with a person disabled by prenatal
alcohol exposure?

   * Structure, consistency, realistic expectations, and more structure.
     It is helpful to think of the necessity for structure in terms of
     needing to provide an environmental exoskeleton for someone
     lacking an internal skeleton which will support them in the daily
     challenges they face.
   * Once appropriate structure is in place we are able to begin work on
     other areas of need, such as behaviors based in FAS/E and/or other
     co-existing conditions. One method of intervention is through
     medication. Various medications are being tried and found useful in
     helping to stabilize these individuals. A medication which shows
     promise, is Depakote in small doses (100 mg.) to reduce the
     incidence of violent acting out.
   * In all areas of endeavor with the client it is necessary to factor
     in their personal abilities, aspirations, and motivations as well
     as their limitations/disabilities relating to the presence of
     FAS/E.

In summary, when we fail to recognize a child or adult with FAS/E, we
set the client and ourselves up for weeks, months or years of one
frustrating treatment failure after another. Standard treatment
modalities for these co-existing mental health diagnoses typically do
not work with an individual with FAS/E. Here the analogy of a personal
computer is useful. It is like trying one software correction after
another in an attempt to address a problem which is inextricably tied to
an underlying hardware malfunction.

Little glimpses of apparent success can keep a professional believing
they are onto something. Then, when the inevitable relapse comes, the
provider’s only refuge is rationalizations that point the blame
somewhere else.  Here, again, it is easy to point the finger at the
parents and accuse them of not providing enough love, consistency,
support, patience, etc. We must objectively evaluate not only the
parents’ contribution to the situation, but our own accuracy in
screening, diagnosing and planning. Ultimately, when we fail to
appropriately assess and address the needs of the consumer, it is just
one more bit of evidence to substantiate the doubts of those who are
skeptical of mental health treatment in general.

However, when needs are properly recognized and diagnosed, treatment


plans can be developed to accurately address them not only for the
individual with FAS/E, but also for the needs of the family or
caregivers. Effective behavior management plans, family/parent support,
case management, advocacy and medication management are a few of the
mental health services which can be provided. The key to success is the
understanding that standard mental health diagnoses by themselves, do
not define the problem nor do they point the way to effective service
provision. When the underlying disability is recognized, it provides a
stable point of reference for appropriate interventions. Under these
circumstances, mental health services can be a very effective avenue to
tackle the problems associated with FAS/E.

(Editor's note: When appropriate assessment and intervention don't
occur, the child can lose hope and  be overwhelmed by rage, as described
in the following poem.)

My Rage Inside
by Mark Waller

The rage I have inside
I can no longer bear.
Is there someone out there that can lend me an ear?
I need someone there,
someone that will care
a friend to talk to
because this I need to share.
Sometimes in my life it seems that no one cares.
Living here is the deepest pit,
full of despair,
that engulfs my life.
Here, where I have no say so
just rules to follow.
This is not the life to live,
not the life for me.
On the outside is
where I’d like to be


 at home with friends and family.
 To most it is a given,
but to me it’s a dream-
something in my life
I may never see.
It was something I had,
but then abused.
It leaves me in question,
my family confused
with all the stupid things
that left me and my friends amused.
It shortly burned up
like a dynamite fuse.
When I got older, it finally blew.
Now in jail
don’t know what to do.
Juvenile life
is what I got.
Now I’m on the inside looking out.
That’s what my rage is all about.

Reprinted from FAS Times, Fall 96