ADDRESSING CO-OCCURING DISORDERS IN SUBSTANCE EXPOSED CHILDREN Clinical Considerations Presenters: Ira J. Chasnoff, M.D. Arthur Krzyzanowski, Psy.D. Children’s

ADDRESSING CO-OCCURING ADDRESSING CO-OCCURING DISORDERSDISORDERS

IN SUBSTANCE EXPOSED IN SUBSTANCE EXPOSED CHILDREN CHILDREN

Clinical ConsiderationsClinical Considerations

Presenters:Presenters:Ira J. Chasnoff, M.D.Ira J. Chasnoff, M.D.

Arthur Krzyzanowski, Psy.D.Arthur Krzyzanowski, Psy.D.Children’s Research TriangleChildren’s Research Triangle

[email protected]@cr-triangle.org

The Children of Substance The Children of Substance Abusing Mothers Either:Abusing Mothers Either:

o Have been prenatally exposed to alcohol and/or Have been prenatally exposed to alcohol and/or drugs and have been diagnosed with FAS/FASD;drugs and have been diagnosed with FAS/FASD;

o Are suspected of having been prenatally Are suspected of having been prenatally exposed, but have not been formally diagnosed;exposed, but have not been formally diagnosed;

o Have no evidence of prenatal substance Have no evidence of prenatal substance exposure.exposure.

© © Children’s Research Triangle 2004Children’s Research Triangle 2004

© Children’s Research Triangle 2004© Children’s Research Triangle 2004

Prenatal Substance Prenatal Substance ExposureExposure

According to a recent study:* 40,000 children/year are diagnosed with FAS Still, 95% of children with FAS go undiagnosed

NOTE: A negative toxicology screening at birth does not mean there was no prenatal alcohol/drug exposure.

* * Lupton, C., Burd, L., & Harwood, R. (2004). Cost of Fetal Alcohol Spectrum Lupton, C., Burd, L., & Harwood, R. (2004). Cost of Fetal Alcohol Spectrum Disorders. American Journal of Medical Genetics, 127C (1), 42-50.


Diagnostic ConsiderationsDiagnostic ConsiderationsAttention Deficit/Hyperactivity DisorderMood Disorders Behavior Disorders Post Traumatic Stress DisorderAnxiety DisordersAttachment DisordersLanguage Based DisordersLearning DisabilitiesPervasive Developmental DisordersAlcohol/Substance Abuse


Treating the Whole ChildTreating the Whole ChildThe emergence of behavioral, emotional,

physical and/or social problems in the children we serve is over-determined!

The child’s development and functioning are influenced by risk factors stemming from:

The ChildThe Parent/Family SystemSociety/Environment


Child Risk FactorsChild Risk FactorsExposure to Toxins In UteroInadequate Prenatal CarePre-maturityBirth Anomalies/DefectsChronic or Serious IllnessTemperamentMental Retardation/Low Cognitive AbilitiesChildhood TraumaInsecure AttachmentsAnti-Social Peer Group


Parental Risk FactorsParental Risk Factors• Active Substance AbuseActive Substance Abuse

• Maltreatment and TraumaMaltreatment and Trauma

• Parent’s Own History of Loss and TraumaParent’s Own History of Loss and Trauma

• Insecure Attachment Insecure Attachment

• Single Parenthood (With Lack of Support)Single Parenthood (With Lack of Support)

• Harsh, Inconsistent or Inadequate ParentingHarsh, Inconsistent or Inadequate Parenting

• Family DisorganizationFamily Disorganization

• Social IsolationSocial Isolation


Parent Risk Factors Parent Risk Factors (Cont.)(Cont.)

High Parental ConflictHigh Parental ConflictDomestic ViolenceDomestic ViolenceSeparation/DivorceSeparation/DivorceParental PsychopathologyParental PsychopathologyIllnessIllnessDeath of Family MemberDeath of Family MemberFoster Care PlacementFoster Care Placement


Social/Environmental Risk Social/Environmental Risk FactorsFactors

o Povertyo Lack of Access to

Medical Care/Social Services

o Parental Unemploymento Homelessnesso Inadequate Childcareo Exposure to racism

o Poor Schools

o Frequent Residence Change

o Environmental Toxins

o Dangerous Neighborhood

o Community Violence


Child Protective Child Protective FactorsFactors

Good HealthPersonality FactorsAbove Average IntelligenceHistory of Adequate DevelopmentHobbies/InterestsGood Peer Relationships


Parental/Family Protective Parental/Family Protective FactorsFactors

• Secure Attachments• Parents Supportive of Child• Household Structure, Monitoring, Rules• Support/Involvement of Extended Family• Stable Parental Relationship• Parents Model Competence/Coping Skills• Family Expectations of Pro-social Behavior• High Parental Education Level


Social/Environmental Social/Environmental Protective FactorsProtective Factors

Middle Class or Above SESAccess to Health Care/Social ServicesConsistent Parental EmploymentAdequate HousingFamily Religious Participation Good SchoolsSupportive Adults Outside of Family


Supporting the Supporting the ChildrenChildren

Trans-Disciplinary ApproachTrans-Disciplinary Approach

o A child’s problems are over-determined, so their treatment needs to be multi-faceted, with risk factors addressed from several directions simultaneously.

o Providers work collaboratively, each bringing their expertise to bear in addressing the child’s needs

o Contrasting the traditional medical model with its reliance on hierarchy (M.D., Ph.D., MSW, OT/PT…)

o No one provider has all the answers. We each hold a piece of the puzzle.


Identifying Needs and Identifying Needs and Accessing Appropriate ServicesAccessing Appropriate Services

Appropriate interventions start with accurate and comprehensive assessments Medical and Psychological Assessment Academic Achievement Occupational Therapy Physical Therapy Developmental Therapy (Ages 0-3) Speech/Language Therapy


Possible Treatment Possible Treatment ProvidersProviders

Addiction Counselor(s)Addiction Counselor(s)Court SystemCourt SystemOccupational TherapistOccupational TherapistPediatricianPediatricianPhysical Therapist Physical Therapist Psychiatrist(s)/Neurologist(s)Psychiatrist(s)/Neurologist(s)Psychologist(s)/Neuropsychologist(s)Psychologist(s)/Neuropsychologist(s)Social Worker(s)Social Worker(s)Speech/Language TherapistSpeech/Language TherapistTeachers/Educational SpecialistsTeachers/Educational Specialists


Intervention StrategiesIntervention Strategies““An ounce of prevention is worth a An ounce of prevention is worth a

pound of cure.”pound of cure.”

• Parent’s Recovery (Pregnancy & Post-partum)• Parent Education, Training and Support• Prenatal and Perinatal Care• Early Identification and Intervention Services

for the infant/child


Maximizing the Impact of Maximizing the Impact of InterventionsInterventions

Intervention strategies that:

o address multiple risk factors rather than focusing on only one factor;

o provide the child and family support in a variety of settings;o work with the family and child over time (2-5 years); ando are initiated as early as possible in the infant’s life

have the greatest potential for positively affecting the outcome of an at-risk child’s development.


O-3/Early Intervention O-3/Early Intervention ServicesServices

MedicalMedicalDevelopmental TherapyDevelopmental TherapyOccupational TherapyOccupational TherapyPhysical TherapyPhysical TherapySpeech/Language TherapySpeech/Language TherapySocial/Emotional DevelopmentSocial/Emotional Development


School-Based School-Based AssessmentsAssessments

• Parent meeting with teachers, administration and associated services

• Multi-disciplinary team meetings; IFSP and IEP Development and Reviews

• Academic Assessment• Psychological Assessment (including IQ)• Speech/Language Therapy• Occupational Therapy• Physical Therapy• Social Work


Sensory Integration (SI) Sensory Integration (SI) DisorderDisorder

Deficits in processing and modulating incoming Deficits in processing and modulating incoming sensory information

FAS/FASD students are more or less sensitive to stimuliLower threshold = Easily overwhelmedHigher threshold = Under-responsive

Treated through Occupational Therapy with a SI focus

Classroom accommodations available to facilitate attention and on task behavior within the classroom


Impact of Sensory Impact of Sensory Processing ProblemsProcessing Problems

May result in considerable agitation and discomfort (both physical & emotional)

May increase distractibility and irritability

Disruptions often lead to impairments in social, emotional and cognitive functioning


SI ResourcesSI ResourcesSensory Integration and the ChildSensory Integration and the Child

A. Jean AyresA. Jean Ayres

The Out-of-Sync Child: Recognizing The Out-of-Sync Child: Recognizing and Coping With Sensory Integrationand Coping With Sensory Integration Carol Stock KranowitzCarol Stock Kranowitz


Psychotherapy Psychotherapy Treatment TechniquesTreatment Techniques

• Picking the right therapy for the individual child:Picking the right therapy for the individual child:

• Attachment TherapiesAttachment Therapies• - Theraplay®- Theraplay®• - Dyadic Developmental Psychotherapy- Dyadic Developmental Psychotherapy

• Experiential TherapiesExperiential Therapies

• Family/Parent-Child TherapyFamily/Parent-Child Therapy

• Behavior Modification TherapyBehavior Modification Therapy

• Parent Psycho-educationParent Psycho-education


Basic Assumptions of Basic Assumptions of TheraplayTheraplay®® www.theraplay.orgwww.theraplay.org

Playful, joyful, Playful, joyful, empathic, attuned empathic, attuned responsivenessresponsiveness

Creation of a more Creation of a more positive relationship positive relationship between children & between children & their parentstheir parents

Roots of Roots of development of self development of self esteem lie in the esteem lie in the early years, thus early years, thus returning to the returning to the derailed derailed developmental stage developmental stage is essentialis essential


Dyadic Developmental Dyadic Developmental PsychotherapyPsychotherapy

Daniel A. Hughes PhD Daniel A. Hughes PhD [email protected]@homestead.com

o Treatment is directive Treatment is directive and client-centeredand client-centered

o Parent is present during Parent is present during sessionssessions

o Playful interactions Playful interactions focused on positive focused on positive affective experiencesaffective experiences

o Nonverbal as well as Nonverbal as well as verbal communicationverbal communication

o Exploration of shame Exploration of shame with empathywith empathy

o Co-regulation of affectCo-regulation of affect

o Therapist and parent Therapist and parent maintain attitude: PACE maintain attitude: PACE (Playful, Accepting, (Playful, Accepting, Curious, Empathic)Curious, Empathic)


Experiential TherapiesExperiential TherapiesSelf-regulation – Combining Sensory Integration into Self-regulation – Combining Sensory Integration into

Psychotherapy Psychotherapy www.alertprogram.comwww.alertprogram.com

Narrative therapy – Creating a coherent autobiographical narrative for the child www.familyattachment.com

Individual/Play TherapySocial Skills Training

NOTE: Insight-oriented therapy typically is not effective with this population given concrete cognitive processes.


Behavioral Behavioral ConsultationConsultation

Identify the problem behaviors Frequency Duration Intensity Context (Precipitating & Sustaining factors)

Identify the student’s strengths


Behavioral Consultation Behavioral Consultation (Cont.)(Cont.)

Concretely define targeted behavior(s) to Concretely define targeted behavior(s) to be eliminatedbe eliminated

Identify substitute behavior or required Identify substitute behavior or required level of performancelevel of performance Always state behavioral goals in the positive Always state behavioral goals in the positive

(“Johnny will do…”) rather than the (“Johnny will do…”) rather than the negative (“Johnny will not…”). Be explicit negative (“Johnny will not…”). Be explicit with the child as to the behavior expected.with the child as to the behavior expected.


Behavioral Consultation Behavioral Consultation (Cont.)(Cont.)

Develop Develop PreventativePreventative and and ReactiveReactive StrategiesStrategies to deal with the to deal with the behavior(s)behavior(s)

Develop a means of assessing Develop a means of assessing behavior changebehavior change

Assessing consultant effectivenessAssessing consultant effectiveness


Parent Psycho-educationParent Psycho-educationEffects of mother’s substance abuse (prenatal

and post-partum) on their child’s developmentAge-appropriate developmental expectationsParenting skills for the behaviorally and/or

emotionally disturbed childAdvocating for services from the larger

communityStructuring child’s environment and effective

limit-setting (Acting as an “External Brain”)


Involvement in the Criminal Involvement in the Criminal Justice SystemJustice System

• According to a long-term study* of adolescents and adults According to a long-term study* of adolescents and adults diagnosed with FASD:diagnosed with FASD:

• 60% of adolescents and adults diagnosed with FASD have 60% of adolescents and adults diagnosed with FASD have been in trouble with the law for various crimes, ranging from been in trouble with the law for various crimes, ranging from shoplifting to domestic violence;shoplifting to domestic violence;

• 53% of men and 70% of women have problems with alcohol 53% of men and 70% of women have problems with alcohol or other drugs (>5 times the general population);or other drugs (>5 times the general population);

• 80% of those in trouble with the law also have problems with 80% of those in trouble with the law also have problems with alcohol/drug abuse.alcohol/drug abuse.

• *Streissguth, a. & Kanter, J. (Eds.). (1997). ( *Streissguth, a. & Kanter, J. (Eds.). (1997). ( The Challenge of Fetal Alcohol The Challenge of Fetal Alcohol Syndrome: Overcoming Secondary DisabilitiesSyndrome: Overcoming Secondary Disabilities. University of Washington Press.. University of Washington Press.


Risk factors associated Risk factors associated with secondary with secondary

disabilities:disabilities:o IQ over 70 (fewer available services)IQ over 70 (fewer available services)

o Exposure to violence (72% of individuals with Exposure to violence (72% of individuals with FASD)FASD)o Those exposed to violence are four time more likely to Those exposed to violence are four time more likely to

exhibit inappropriate sexual behaviorexhibit inappropriate sexual behavior

o Perception/attitudes of authoritiesPerception/attitudes of authoritieso ““If you look normal, then you must be normal.”If you look normal, then you must be normal.”

o ““They seem bright; they should know right from wrong.”They seem bright; they should know right from wrong.”


Protective Factors:Protective Factors:

Early diagnosisEarly diagnosisEligibility for services (i.e. MR/DD)Eligibility for services (i.e. MR/DD)Living in a stable homeLiving in a stable homeProtection from violenceProtection from violence


Addressing the Legal Addressing the Legal IssuesIssues

Educate judges and lawyers about FAS/FASD:Educate judges and lawyers about FAS/FASD:Capacity: Understanding of right from wrong Capacity: Understanding of right from wrong

is impairedis impairedCompetency: Understanding of charges and Competency: Understanding of charges and

their rightstheir rightsSentencing: Extenuating circumstancesSentencing: Extenuating circumstances

Alternative sentencingAlternative sentencingTreatment optionsTreatment optionsEnvironmental support and structure Environmental support and structure


SCREAMS – Seven Secrets to SCREAMS – Seven Secrets to Success with FAS in the Court Success with FAS in the Court

SystemSystem©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman

www.Fasstar.comwww.Fasstar.com• SStructure• CCuesues• RRole Modelsole Models• EEnvironmentnvironment• AAttitude of Othersttitude of Others• MMedicationedication• SSupervisionupervision


SSCREAMSCREAMS©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman

www.Fasstar.comwww.Fasstar.com

STRUCTURE:STRUCTURE: Daily routine, unchanging schedule, Daily routine, unchanging schedule,

concrete rules and simple directions.concrete rules and simple directions. They would do well in prison, but not so They would do well in prison, but not so

well on probation or living independently.well on probation or living independently.


SSCCREAMSREAMS©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman


CUESCUES: : Memory deficits result in need for constant Memory deficits result in need for constant

reminders reminders Visual prompts, picture symbolsVisual prompts, picture symbols SchedulesSchedules Learning and re-learning, Learning and re-learning,

practice/rehearsalpractice/rehearsal


SCSCRREAMSEAMS©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman


ROLE-MODELS: ROLE-MODELS: Mentors, coaches, positive peersMentors, coaches, positive peers 1:1 assistance1:1 assistance Role-playing situations with repetition to Role-playing situations with repetition to

develop social competence and skillsdevelop social competence and skills


SCRSCREEAMSAMS©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman


ENVIRONMENT:ENVIRONMENT: SI deficits intensify reactions. SI deficits intensify reactions. Arrests feel like assaults, confined space Arrests feel like assaults, confined space

can be suffocating, handcuffs painfulcan be suffocating, handcuffs painful Lights, noise, activity level can be Lights, noise, activity level can be

overwhelming and elicit an aggressive overwhelming and elicit an aggressive (self-protective) response(self-protective) response


SCRESCREAAMSMS©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman


ATTITUDE OF OTHERS:ATTITUDE OF OTHERS: “They should know better.” “They’re incorrigible.” Willful/defiant Lazy or “not working up to their potential”


SCREASCREAMMSS©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman


MEDICATION:MEDICATION: Right meds can restore limited control over Right meds can restore limited control over

mood and behaviormood and behavior Wrong or inappropriate medication can Wrong or inappropriate medication can

exacerbate mood and behavior exacerbate mood and behavior dysregulationdysregulation


SCREAMSCREAMSS©2000-2002 Teresa Kellerman©2000-2002 Teresa Kellerman


SUPERVISIONSUPERVISION: : FAS/FASD clients involved in the criminal FAS/FASD clients involved in the criminal

justice system likely will require on-going justice system likely will require on-going support and monitoring.support and monitoring.


Additional Resources:Additional Resources:

For more information about FAS/FASD and the For more information about FAS/FASD and the Criminal Justice System, please check out the Criminal Justice System, please check out the following website:following website:

www.come-over.to/FAS/Courtwww.come-over.to/FAS/Court

Which provides and overview of the issue, as Which provides and overview of the issue, as well as links to relevant articles and websites.well as links to relevant articles and websites.


A Parable about Problem-SolvingA Parable about Problem-SolvingA person standing near a river hears a call for help and sees someone drowning. He jumps in and pulls the struggling swimmer out of the water and resuscitates him. As he finishes resuscitating the first swimmer, a second cries out. Again, he enters the water and with great effort hauls the second drowning person ashore. A third person calls out for help and he jumps to the rescue and nearly drowns in the effort, but manages to pull the third person out of the river. An admiring crowd has gathered when a fourth person calls for help and our hero walks away. “Where are you going? What about this person who is drowning?” He turns and says, “I’m tired of rescuing people from the river. I’m going upstream to find out who’s pushing them in!”

Quoted from McGourty & Chasnoff (2003). Power Beyond Measure. Chicago, IL: NTI Publishing.


www.childstudy.org

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ADDRESSING CO-OCCURING DISORDERS IN SUBSTANCE EXPOSED CHILDREN Clinical Considerations Presenters: Ira J. Chasnoff, M.D. Arthur Krzyzanowski, Psy.D. Children’s