Upload
chapmack3094
View
156
Download
3
Tags:
Embed Size (px)
DESCRIPTION
Master's Case Presentation in the Faculty of Behavioural Sciences at Yorkville University. A 16 year-old adolescent male and his mother self-referred for treatment to cope with the adolescent’s extreme behaviours. Past assessments revealed a diagnosis of attention-deficit hyperactivity disorder (ADHD). Comorbid symptomatolagy included explosive outbursts, childhood abuse, substance use, disrupted attachment, and negative school and social experiences. Upon the mother’s self-disclosure of alcohol use in pregnancy, suspicions arose that her son had an undiagnosed fetal alcohol spectrum disorder (FASD) underlying his behaviours. A referral for a multidisciplinary assessment was made which confirmed a diagnosis on the FASD continuum. A wide range of treatment strategies were employed over 14 months, including parent training and support, psychoeducation around ADHD and FASD, skills building, and modified cognitive-behavioural techniques. Interventions were family-centred, strengths based and attempted to accommodate the identified client’s neurobehavioral deficits and underlying brain dysfunction. A paucity of research for evidence-based interventions in FASDs proved challenging therefore, continuing interventions used interdisciplinary research and a variety of extant literature as reference sources. A multimodal approach to therapy and the quality of the therapeutic relationship became essential to the family’s stabilization and progress.
Citation preview
YORKVILLE UNIVERSITY
Family-Based Treatment of Attention-Deficit Hyperactivity Disorder and Fetal Alcohol
Spectrum Disorder in an Adolescent Male
by
Hannah Chapman McCormack
A MASTER’S CASE PRESENTATION
SUBMITTED TO THE FACULTY OF BEHAVIOURAL SCIENCES IN PARTIAL
FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS IN COUNSELLING PSYCHOLOGY
Fredericton, New Brunswick
April 26th
, 2011
Running head: FAMILY TREATMENT OF ADHD AND FASD 2
Abstract
A 16 year-old adolescent male and his mother self-referred for treatment to cope with the
adolescent’s extreme behaviours. Past assessments revealed a diagnosis of attention-deficit
hyperactivity disorder (ADHD). Comorbid symptomatolagy included explosive outbursts,
childhood abuse, substance use, disrupted attachment, and negative school and social
experiences. Upon the mother’s self-disclosure of alcohol use in pregnancy, suspicions arose
that her son had an undiagnosed fetal alcohol spectrum disorder (FASD) underlying his
behaviours. A referral for a multidisciplinary assessment was made which confirmed a diagnosis
on the FASD continuum. A wide range of treatment strategies were employed over 14 months,
including parent training and support, psychoeducation around ADHD and FASD, skills
building, and modified cognitive-behavioural techniques. Interventions were family-centred,
strengths based and attempted to accommodate the identified client’s neurobehavioral deficits
and underlying brain dysfunction. A paucity of research for evidence-based interventions in
FASDs proved challenging therefore, continuing interventions used interdisciplinary research
and a variety of extant literature as reference sources. A multimodal approach to therapy and the
quality of the therapeutic relationship became essential to the family’s stabilization and progress.
FAMILY TREATMENT OF ADHD AND FASD 3
Acknowledgments
I wish to thank my supervisors, Lloyd Garner and Isabelle Majnaric, for their assistance,
support, and mentorship during my practicum placement. Their guidance enabled me to provide
services to my clients in a responsive and knowledgeable way. I am also grateful to all the staff
of the CFEC for their part in this case presentation coming to fruition. I also wish to
acknowledge my husband, John McCormack, without whom the completion of this case
presentation would not have been possible. My gratitude also goes out to all the faculty of
Yorkville University for their patience, expertise, and encouragement. I wish to dedicate this
work to all my family, friends, and colleagues, as well as to all the clients who touched me
professionally and personally during our work together.
FAMILY TREATMENT OF ADHD AND FASD 4
Contents
Page
Title Page ............................................................................................................................... 1
Abstract ................................................................................................................................. 2
Acknowledgements ................................................................................................................ 3
Introduction ........................................................................................................................... 6
Case Information .................................................................................................................... 6
Biopsychosocial History and Screening ............................................................................. 8
Mental Status and Risk Assessment ................................................................................. 12
Initial Assessments .......................................................................................................... 14
Therapy Outcome Measures ............................................................................................ 17
Literature Review ................................................................................................................. 18
Attention Deficit Hyperactivity Disorder ......................................................................... 18
Treating Attention Deficit Hyperactivity Disorder ........................................................... 24
Fetal Alcohol Spectrum Disorders ................................................................................... 33
Treating Fetal Alcohol Spectrum Disorders ..................................................................... 49
Association between Attention Deficit Hyperactivity Disorder and Fetal Alcohol Spectrum
Disorders.............................................................................................................................. 63
Literature Review Summary ................................................................................................. 65
Case Formulation ................................................................................................................ 66
Diagnostic Impression ..................................................................................................... 66
Figure 1 Multiaxial Assessment ....................................................................................... 72
Treatment Plan ................................................................................................................ 73
FAMILY TREATMENT OF ADHD AND FASD 5
Treatment Summary ............................................................................................................. 81
Month One ...................................................................................................................... 81
Month Two ..................................................................................................................... 87
Month Three ................................................................................................................... 93
Month Four ..................................................................................................................... 96
Month Five ...................................................................................................................... 99
Months Six to Nine ........................................................................................................102
Month Ten .....................................................................................................................103
Months Eleven to Fourteen .............................................................................................103
Results ................................................................................................................................104
Case Impressions ............................................................................................................104
Case Recommendations ..................................................................................................106
Discussion ...........................................................................................................................107
Personal Reactions to the Case .......................................................................................105
What I Learned from the Case ........................................................................................107
Personal Implications .....................................................................................................107
Implications for my Clients ............................................................................................108
Implications for the Field ...............................................................................................109
References ..........................................................................................................................110
Appendix A: Diagnostic Criteria for ADHD ........................................................................147
Appendix B: Counselling Sessions Rating Scale .................................................................148
FAMILY TREATMENT OF ADHD AND FASD 6
Family-Based Treatment of Attention-Deficit Hyperactivity Disorder and Fetal Alcohol
Spectrum Disorder in an Adolescent Male
Nancy1, a 46-year-old white female of Greek ancestry and her 16-year-old biological son,
Todd, self-referred for therapy and general support services. Nancy made initial contact over the
telephone requesting parenting strategies and family support. Nancy had seen an advertisement
for a parent-to-parent group for caregivers of children with complex developmental and
behavioural conditions offered by our agency. She was curious if it would meet her needs and
was interested in counselling for both herself and her son on an ongoing basis.
Case Information
Mother’s perspective. Nancy explained via telephone that her son Todd was exhibiting
a number of maladaptive behaviours that were affecting his own well-being and that of the
family. Nancy cited a long list of complaints regarding Todd’s behaviour including shoplifting,
property damage, lying, substance use, repeated school suspensions, ongoing trouble with the
justice system and verbal threats. Nancy mentioned that when Todd experienced any major
changes in routine, he became anxious and destructive.
The family had recently relocated from the city and Nancy expressed that she was not
currently receiving any community services or assistance. The family now lived in a high-risk
neighbourhood in a rural area outside of the main town. Nancy admitted to feeling frustrated,
overwhelmed, and isolated. She was also aware that the tension between her and Todd was
negatively affecting their relationship. Nancy said Todd was willing to try therapy to address
some of his challenges and issues and to learn new skills to cope with his anger. Nancy wanted
education, support, and a safe place to express herself without judgement and blame.
1 Client names and other identifying features have been changed to protect their identity and privacy.
FAMILY TREATMENT OF ADHD AND FASD 7
In terms of past assessments or diagnoses, Nancy disclosed that Todd had a diagnosis of
Attention-Deficit Hyperactivity Disorder (ADHD) but she could not accurately recall all the
pertinent details. She alluded to a discharge report from the resident psychiatrist at an inpatient
adolescent psychiatric hospital Todd had attended the past year. However, Todd was not
receiving any ADHD based or other interventions at the time of intake.
Son’s perspective. Todd also spoke to me via telephone about his experience of events.
Todd expressed that he was frustrated and overwhelmed when his mother yelled at him and was
tired of her constant demands and high expectations. However, he was averse to coming into the
office on a regular basis despite these difficulties at home. My assurances that Todd would not
be required to remain in therapy against his will appeared to assuage some of his resistance.
When prompted, Todd reported symptoms of forgetfulness, impulsivity, anxiety,
restlessness and feelings of anger. Todd indicated that he often felt overwhelmed and that he
frequently exploded when he felt aggravated. He appeared to have few coping skills to deal with
his feelings. He was aware that his behaviour had caused him problems in the past with his
peers, family, and the community. He volunteered that he disliked school, and was relieved he
was on suspension.
In regards to the substance use Nancy reported, Todd did not view his usage as a
problem. He asserted that marijuana helped him calm down and focus, and that alcohol made
him forget his problems. His usage had not increased over the past few years, but he had been
using substances from a young age. Todd admitted to often smoking marijuana and drinking
alcohol with friends, but was adamant that he had been able to stop voluntarily for long periods
when required.
FAMILY TREATMENT OF ADHD AND FASD 8
Intake session. Nancy and Todd agreed to come to the agency for an in-person intake
session. Mother and son were informed in advance what to expect from the first session. Nancy
volunteered to bring in all supporting documentation on Todd that she could find including
psychoeducational reports, school reports cards, psychiatric discharge summaries, and other
medical forms.
Upon arrival, Nancy and Todd were both dressed very casually. Todd was wearing a
camouflage jacket, jeans, runners and a baseball hat. Nancy was wearing pajama-style clothes
that had a few holes and some noticeable stains. Nancy was an obese woman with dark curly
hair. Todd was tall and thin with light-coloured eyes and hair. He had mild acne and yellow
teeth stains from smoking. Todd said he preferred to keep his baseball hat on because it
minimized overwhelming light and noise.
According to agency policy, the clients completed an intake assessment, an in-depth
background questionnaire, and read and signed informed consent and confidentiality policies.
The relevant information was simplified and adapted for Todd to ensure maximum
comprehension and understanding. The clients were both give their own copies and encouraged
to ask questions at any point in the therapy process.
Biopsychosocial History and Screening
Past assessments, complimented by a variety of documentation and the clients’ own
recollections, provided sufficient information to compile an extensive psychosocial history after
the intake session.
Developmental history and status. Nancy reported that her pregnancy with Todd was
extremely stressful. The pregnancy was unplanned and remained unknown until 12 weeks
gestation. Nancy disclosed that her husband had been abusive toward her throughout and after
FAMILY TREATMENT OF ADHD AND FASD 9
her pregnancy. When asked how she handled the stress of an abusive relationship, Nancy
divulged that alcohol was her primary coping mechanism.
In regards to her alcohol consumption in pregnancy, Nancy was hesitant to reveal any use
at first. After assurances that many women consume alcohol before they are aware of their
pregnancy, Nancy stated that it was probable that she drank before she knew she was pregnant.
When asked about quantity, frequency, and dosage, Nancy revealed that her usual alcohol
consumption prior to pregnancy was two to six beers daily. Nancy expressed that she most
likely consumed alcohol at this rate during the first 12 weeks of Todd’s prenatal development.
Nancy recounted that Todd was a colicky baby who had trouble sleeping, and was prone
to temper tantrums and accidents. Nancy admitted he was difficult to comfort and hard to feed.
Overall, ease of attachment between Nancy and Todd was apparently difficult. Todd witnessed a
number of episodes of domestic violence between his parents as a young child. Todd also
showed early delays in his attainment of developmental milestones. By Nancy’s attestation,
Todd did not walk until two and a half years of age, and was unable to speak in phrases until he
was around four years of age. Nancy and her husband ultimately divorced when Todd was four
years old and Todd only saw his father intermittently at the time of intake.
Educational history and status. School report cards recorded that Todd had been on a
modified educational program since Kindergarten. An early psychoeducational report recorded
problems with receptive language, following oral instruction, remembering auditory information
and displaying appropriate classroom behaviour. One of the recommendations from his school
psychologist at this time was to undergo a neurodevelopmental examination and assessment,
although Nancy did not follow-up.
FAMILY TREATMENT OF ADHD AND FASD 10
At age 13, Todd underwent a secondary psychoeducational assessment that refers to
pervasive difficulties with verbal recall, attention, organization and focus. Todd’s adaptive
functioning behaviour score fell into the Extremely Low range. The school psychologist made a
recommendation for Todd to receive specific instruction in communication, social skills and life
skills from a counsellor. Then at age 15, Todd attended an alternate school on a modified
program that focused on life skills training. Todd was given up to six hours of learning
assistance per week. During this time, Todd’s truancy was an issue for the teachers, as well as
his substance use, classroom behavioural problems (noted to arise from frustration), and
domestic issues that spilled over into the school environment. However, Todd’s teachers
recognized that Todd could be very personable when offered the right type of motivational
rewards.
Todd was on academic suspension for truancy at the time of the intake session. He was
supposed to be attending a special needs educational program at the local high school working
towards a school completion certificate. Apparently, Nancy had left Todd alone to get to and
from school while she was out of town working. Without any structure or prompting, Todd was
unable to get up in the morning and get to school. Todd indicated that he would rather find
employment than return to school.
Mental health history and status. Todd exhibited depressive symptoms sporadically
and became anxious when faced with unexpected changes to his daily routine. School reports
showed that Todd received an ADHD combined type diagnosis in second grade and that he took
Dexedrine for a short period. Nancy did not bring Todd back for follow-up appointments with
the psychiatrist after the first round of medication. Nancy stated that Todd’s only other mental
FAMILY TREATMENT OF ADHD AND FASD 11
health intervention as a child had consisted of family counselling for exposure to domestic
violence.
When Todd was 14 years old, Nancy admitted him to an inpatient adolescent psychiatric
setting in response to extreme behaviours. Todd’s assessment included a renewed diagnosis for
ADHD combined type. The psychiatrist believed that Todd’s comorbid symptoms (i.e., conduct
issues, anger outbursts, and substance use) were derivative of his ADHD and factors resulting
from his home environment. The psychiatrist did not believe Todd’s symptoms to be worthy of
separate diagnostic classification, rather he noted they were interwoven with Todd’s neurological
weaknesses and vulnerability to overstimulation. In regards to medication for ADHD, the
psychiatric discharge report indicated that Todd refused a trial of medication, and that
maintaining consistency was a concern. However, Nancy stated that the psychiatrist was the one
reluctant to prescribe medication to Todd because he thought Todd would try to sell it on the
street for profit.
The psychiatrist also documented parent-child relational or attachment problems. He
wrote that Nancy needed skills around how not to trigger and exacerbate Todd’s emotional
distress. However, the most significant memo was that Todd’s family history strongly suggested
a possibility of a Fetal Alcohol Spectrum Disorder (FASD). There were no notations for follow-
up or assessment.
After his two-week inpatient stay, Todd attended a five-week residential skills building
program to address his range of psychosocial needs and deficits. Treatment occurred in a group
setting, and centred on life and social skills development. The discharge summary mentioned
that Todd had difficulties generalizing new learning.
FAMILY TREATMENT OF ADHD AND FASD 12
Vocational history and status. Todd and Nancy both reported that Todd had barriers to
finding and sustaining employment. Todd had worked in a few family restaurants, but his
placements had ended in dismissal. Todd said he often forgot to show up for work and
overlooked duties. Todd said he preferred “hands-on” activities and other kinaesthetic and
tactile pursuits. He liked building, designing and working outdoors.
At the time of intake, Todd was not working and was spending his days at home playing
video games, or wandering around town to socialize with a negative peer group. Nancy received
government income assistance, and worked on-call as a house cleaner. Nancy was the sole
supporter of the family, and her work often took her to outlying areas over an hour away.
Legal history and status. At age 14, Todd was on probation for one year for stealing
Nancy’s car. He was required to attend an educational program for adjudicated youth each week
of his probationary period. Todd had constant supervision during the program and Nancy felt he
was extremely successful in the program while it lasted. Todd explained that he was now on
probation for a second time for shooting three younger adolescents with a pellet gun from behind
a trash compactor on school grounds. Todd stated that a friend had encouraged him to take part
in the crime, but Todd was the only one caught. Todd did not seem to understand the impact of
his actions or the real possibility of sentencing to a juvenile detention facility at an upcoming
court date. Todd mentioned his probation officer only saw him once a month for 15 minutes at a
time.
Mental Status and Risk Assessment
As part of the clinical assessment, a mental status assessment was conducted based on
observations of the family at the time of the intake session (Saddock & Saddock, 2007).
FAMILY TREATMENT OF ADHD AND FASD 13
Mental status evaluation. At the time of the initial interview, both Nancy and Todd
were coherent, lucid and appeared to be functioning at acceptable levels relative to their history.
Todd’s inattentiveness was noticeable, as he constantly fidgeted and peered out the window.
When directly engaged (i.e., using his name and eye contact to grasp his attention), Todd was
friendly and smiled often. However, his affect was often inappropriate in regards to the subject
matter under discussion.
In terms of memory and functioning, Todd’s comprehension of lengthy statements
appeared impaired. His expressive language seemed intact compared to his receptive abilities,
but his narrative was often disjointed and superficial. He squirmed in his seat and abruptly rose
and moved around the room. Todd’s long-term recall was also stronger than his short-term
recall. Nancy expressed that his behaviour was typical of his current functioning.
When recounting events, Nancy’s mood conveyed frustration. Nancy was quite verbal
yet had flat affect. She also seemed confused by incoming information and her overall retention
seemed poor like her son. The accompanying documentation she brought to the session filled in
the gaps in her personal narrative. Nancy demonstrated impairments in semantics, often using
the wrong words, or turn of phrase in her communication.
The family showed marked resiliency and tenacity in the face of their extreme
difficulties. Todd seemed to perform well in structure and routine when it was consistent.
Nancy had proven herself creative in accessing resources in the past. Both Todd and Nancy
were open and willing to access assistance and learn new skills. By the end of the intake session,
Nancy expressed that she had some feelings of hope. Todd was also agreeable to further work.
The level of rapport between all parties was high, and both mother and son said they wished to
FAMILY TREATMENT OF ADHD AND FASD 14
return to develop a treatment plan. However, from the first session with the family, it was
apparent that modifications to the traditional therapy process would be required.
Risk Assessment. Due to numerous references to anger outbursts, past abuse, and
substance misuse, a risk assessment was undertaken. Todd apparently had the ability to be
explosive according to his mother and other reports, but in-person he presented as friendly and
cheerful. There was no immediate sense of danger or any attempt on Todd’s part to intimidate,
control, or act out. It appeared to me that his outbursts might be reactive rather than intentional
and premeditated. Neither Nancy nor Todd reported current ongoing abuse, nor was there any
physical evidence of abuse observed. I gave Nancy and Todd information on the legalities and
the agency policy on the disclosure of the abuse, neglect, or harm of a child.
Both Nancy and Todd self-disclosed to using marijuana and alcohol at different points in
time. Nancy asserted that she drank minimally compared to when Todd was young. Neither
Nancy nor Todd felt their substance use was problematic. Both were adamant that they were not
interested in any kind of treatment for Todd, or in-depth substance use therapy. They were open
to learning more about the effects of this behaviour in future sessions. Nancy was encouraged to
refrain from using substances of any kind around Todd.
Initial Assessments
After the intake session, we decided that treatment would focus on Todd’s ADHD and
related behavioural and skills deficits while concurrently addressing Nancy’s stress levels and
lack of coping ability. Nancy needed parenting education by her own volition, and desired
connection with community resources and the parenting support group. Todd was in need of
further adaptive and vocational training as well as strategies for coping with the hardships of
daily life. He lacked tools for self-regulating his negative emotions and thoughts. I believed that
FAMILY TREATMENT OF ADHD AND FASD 15
if Todd had enough support to develop his strengths and abilities, he would experience an
increase in self-worth and a decrease in feelings of inadequacy and frustration.
Based on the family’s background information, I believed that Todd should undergo a
screening assessment for a FASD. Todd had no dysmorphic facial features or apparent growth
deficiencies but his psychiatrist had noted a FASD could be behind his unique profile of
challenging behaviours. Todd’s extreme behavioural symptoms were therefore potentially
indicative of central nervous system injury from prenatal alcohol exposure (PAE). This could
potentially classify him in the alcohol-related neurodevelopmental disorder (ARND) category.
Todd’s challenges across multiple areas of functioning were consistent with the typical
symptomatolagy of FASD. If the screening indicated a potential FASD, Todd would need to a
referral to a multidisciplinary assessment team for further investigation.
FASD screening. Nancy and Todd attended a follow-up screening intake to discuss the
possibility of a FASD. They received basic educational information about the continuum of
FASD, and its neurobehavioral accompaniments and common manifestations. Since Todd’s
behaviour was escalating, and previous interventions had proven successful only on a temporary
basis, the family was willing to gather more information on the subject. With a paediatric
referral, Todd could access the waitlist immediately.
Nancy and Todd looked at Todd’s psychiatric discharge report from the hospital, where
the psychiatrist queried the possibility of a FASD. A discussion regarding the benefits of
identification ensued, and the family agreed to perform the basic screening tools first and
observe what they yielded. There are no standardized screening tools for FASD at this level, but
the tools used were helpful in determining whether there was merit in further investigation.
FAMILY TREATMENT OF ADHD AND FASD 16
FASNET assessment tool. The FASNET assessment tool (Berg, Kinsey, Lutke &
Wheway, 1995) was administered with the clients. Its intended use is for children aged 14 to 18
years. The tool is a comprehensive non-medical screening device to assess whether or not to
refer a child for a FASD assessment. Generally, if a child had confirmed PAE and their score on
the screening tool is higher than 50% the authors recommend a doctor referral. A doctor can
then refer the child for an appropriate neurobehavioural assessment. The tool covers everything
from postnatal history, physical findings, and communication to impulsivity, memory and
cognition. Todd scored a 227 out of a possible 273 points or 83.2% on the screening tool.
FAS screening form. Burd, Martsolf and Jeulson (2004) developed a simple screening
tool for suspected FASDs in the criminal justice system. This screening tool mainly focuses on
the well-known physical characteristics associated with FASDs. However, it also includes a
developmental impairment section, which addresses mental retardation, speech and language
delays, hearing and vision problems, attention and concentration issues and hyperactivity. If an
individual scores over 20 points on the screening form, a doctor referral is recommended. On
this screening tool, Todd scored 21 points.
FASCETS neurobehavioral pre-screening tool. Diane Malbin (2008) developed this
tool to support the exploration, identification and referral of FASDs. This screening tool
explores the links between problematic behavioural symptoms and underlying brain dysfunction.
Results are scored on a five-point Likert scale with a one standing for “no issues” and a five
standing for “always issues”. The higher the scores tally, the higher the recommendation for
referral. Todd’s scores in all areas were extremely high, well within the 4 to 5 point range of
multiple domains.
FAMILY TREATMENT OF ADHD AND FASD 17
Malbin’s (2008) tool also recognizes the need to screen for strengths including interests
and talents. Todd scored high in athleticism, mechanical inclination, creativity, friendliness, and
determination and his learning style was relational, visual and kinaesthetic. Todd learned best
from concrete and experiential teaching in one-on-one relational scenarios.
FASD screening results. I gave the family paperwork for their pediatrician querying a
FASD and requesting a professional multidisciplinary assessment based on Todd’s high scores
on all three screening tools. The waitlist for a professional assessment from the regional testing
centre was typically three or more months.
Therapy Outcome Measures
I created a brief self-report questionnaire to measure therapy progress for the family (See
Appendix B). Nancy and Todd agreed to complete it at the end of each month of treatment. The
form was adapted from Duncan and colleagues’ brief Session Rating Scale Version 3 (SRS;
2003). The revised form aimed to be simple and straightforward, and catered to Todd and
Nancy’s reading abilities. The focus of the form was to rate the perceived quality of the
therapeutic relationship as a successful predictor of successful therapy outcomes (Orlinsky,
Rønnestad, & Willutzki, 2003).
Although self-report measures are subjective (and therefore not as clinically reliable as
standardized assessments), there are research examples to support the validity of such measures
for reports of subjective well-being (Barlow, 2005; Fischer, 2004; Sandvik, Diener, & Seidilitz,
2009). The desirability of self-report measures lies in their simplicity of use, their non-intrusive
nature, and their overall cost-effectiveness (Barlow, 2005; Fischer, 2004).
FAMILY TREATMENT OF ADHD AND FASD 18
Literature Review
Attention-Deficit Hyperactivity Disorder
Dr. Larry Merkel a psychiatrist from the University of Virginia defines ADHD as a
“heterogeneous syndrome of unknown etiology that effects attention, motor activity, and
executive functioning with variable outcome and high rates of psychiatric comorbidity, resulting
in a great deal of distress and disability” (Merkel, n.d, para.1.). ADHD is a complex disorder
that impairs multiple domains of functioning (Pelham & Gnagy, 1999). Researchers believe that
ADHD is the result of a number of potential sources, or causal factors, including heredity,
neurology, toxic influences, and other prenatal and postnatal factors (Barkley, 1996).
Epidemiology. ADHD is the most prevalent chronic psychiatric and/or neurobehavioral
disorder diagnosed in children and often persists into adulthood (Barkley, 1998; Furman, 2002).
Prevalence rates vary between 3-12% of general child populations and sit around 7.8% of the
general adult population (Biederman & Faraone, 2006; Evans et al., 2006; Gioia & Isquith, 2002;
Rowland et al., 2002). Merikanayas and colleagues (2010) state that boys are diagnosed with
ADHD three times as often as girls in the United States are, and that the lifetime prevalence of
ADHD for adolescents 13 to 18 years in the United States is 9%. However, prevalence rates can
be over 50% in child clinical settings (Evans et al., 2006).
General symptoms. Attentional problems, excessive motor activity, and difficulty
controlling impulsive responding lie at the core of ADHD symptomatolagy (Ingersoll &
Goldstein, 1993). The Diagnostic and Statistical Manual of Mental Health Disorders, Fourth
Edition, Text Revision (DSM-IV-TR, APA, 2000) cites the principal symptoms of ADHD as
inattentiveness, hyperactivity, and impulsivity. Hyperactivity may wane with age, but the other
hallmarks of the disorder remain consistent (Kewley, 1999).
FAMILY TREATMENT OF ADHD AND FASD 19
Many youth with ADHD report an increase in internalizing symptomatolagy during their
adolescence (e.g., anxiety, depression, or lowered self-esteem) on top of standard externalizing
behaviours (Acro, Fernandez, & Hinojo, 2004). Adolescents with ADHD can suffer from
disruption of normal developmental processes and complex learning disorders (Weiss &
Hechtman, 1993). Foreseeing consequences can be impaired, lack of motivation, lower
educational and vocational attainment, unhealthy social relationships, behavioural problems and
impulsive choices are standard (Ingersoll & Goldstein, 1993; Mattheis, 2007; Weiss &
Hechtman, 1993; Whalen, Jamner, Henker, Delfino, & Lozano, 2002).
ADHD diagnosis. There is no definitive diagnostic test for ADHD, although there are a
number of screening methodologies. Opie (2006) states that “a patient’s reported history of
characteristic symptoms and functional impairment, which must have been present at least since
seven years of age, and a clinician’s assessment of whether the patient meets accepted diagnostic
criteria” (p. 2638) are factors necessary for ADHD identification. Appendix A outlines the
DSM-IV-TR criteria for ADHD in more detail (APA, 2000). Patients need to display at least six
of the listed symptoms in Appendix A, for a minimum of six months, and in more than one
setting for diagnosis. Diagnosis is largely subjective and based on the observation of patterns of
inattention, impulsivity, and hyperactivity from parent and teacher reports and according to the
diagnostic criteria of the DSM-IV-TR (APA, 2000).
ADHD and the brain. In the past 15 years, brain-imaging technology has revealed a
plethora of new information on the differences found in brains affected by ADHD. Biederman
and Faraone (2006) report on studies that show abnormal activation of the cerebral area in
response to cognitive demand in individuals with ADHD. Studies have shown that individuals
with ADHD have decreased blood flow to parts of the prefrontal cortex region, as well as
FAMILY TREATMENT OF ADHD AND FASD 20
problems in levels of neurotransmitter functioning, specifically dopaminergic communication
(Ernst et al., 1999; Spalletta et al., 2001). Additionally, brain structure and brain wiring exhibit
deviations from the norm in several areas of a brain affected by ADHD (Giedd, Blumenthal,
Molloy, & Castellanos, 2001). For example, one anatomical study of the brains of persons with
ADHD reported a 4% reduction in brain volume from the norm, specifically in the areas of the
cerebrum and cerebellum (Biederman & Faraone, 2006).
Executive functioning. ADHD is associated with an ineffective use of higher order brain
processing (Barkley, 1997). The term executive functioning (EF) describes the sophisticated
processes in the brain that encompasses tasks like working memory, alertness, self-monitoring,
flexibility, self-regulation, motivation, activation, problem-solving action, goal-directed
behaviour, and reconstitution (Barkley, 1997; Biederman et al., 2004; Denckla, 1994; Schachar
et al., 2004). Gioia and Isquith (2002) contend that “the executive functions play a fundamental
role in the child’s cognitive, behavioural, and socio-emotional development with substantial
implications for everyday academic and social functioning” (p. 5).
Many researchers believe that impairments in EF directly lead to the behavioural
symptoms associated with ADHD (Barkley, 1998; Biederman et al., 2004; Gioia & Isquith,
2002; Kendall, Reber, McLeer, Epps, & Ronan, 1990; Schachar et al., 2004). For example, an
EF deficit such as low frustration tolerance can lead to aggression, impatience and reduced
objectivity in a person with ADHD. Subsequently, this may lead to an increase in risk-taking
behaviour and impulsive decision-making. Risk-taking behaviour and impulsivity are associated
with a host of secondary problems, including trouble with the law, academic struggles and
fractured interpersonal relationships (Schachar et al., 2004).
FAMILY TREATMENT OF ADHD AND FASD 21
ADHD and psychosocial functioning. Persons with ADHD can suffer from lifelong
interpersonal and learning difficulties if left untreated (Acro et al., 2004; Okie, 2006; Robbins,
2005; Thomas, Sather, Whinery, 2008). Early recognition, assessment, and management of
ADHD can lead to better psychosocial outcomes in children (Cantwell, 1996). However, even
with adequate intervention, research shows that ADHD symptoms persist into adulthood for 40
to 60% of childhood patients, causing disruptions in their professional and personal life (Harpin,
2005; Okie, 2006). Sometimes apparent improvements in ADHD symptoms result from
maturation rather than from specific treatments (Emerson, 2000). ADHD affects the entire
family system and has links to disturbances in marital functioning, parent emotional health and
family cohesion (Harpin, 2005; Klassen, Miller, & Fine, 2004).
Mental health. The lowered self-esteem found in children with ADHD can quickly
reduce their chances of adult success and quality of life (Okie, 2006). Krueger and Kendall’s
(2001) study of adolescents with ADHD found that 65% of their sample suffered from comorbid
psychiatric and developmental disorders. In 2008, the Harvard Mental Health Letter reported
that 54 to 84% of individuals with ADHD meet the criteria for oppositional defiant disorder
(ODD). Anxiety, conduct disorder, challenging behaviour, and substance abuse are also
common comorbidities of ADHD (Kewley, 1999).
Low self-esteem and fractured relationships. Robbins (2005) states that children with
ADHD experience intense personal criticism for their behaviour from peers and adults alike. EF
shortfalls result in organizational and memory deficits that appear as a host of undesirable
behaviours from chronic lateness and disorganization in childhood to unpaid bills and missed
appointments in adulthood. Unfortunately, some view these neurobehavioural symptoms are
moral defects. The child with ADHD’s lack of ability to attend for extended periods, smoothly
FAMILY TREATMENT OF ADHD AND FASD 22
transition between activities, or independently initiate tasks is often miscategorised as defiance,
stubbornness, manipulation or laziness (Robbins, 2005).
This criticism and failure to live up to others expectations can result in chronically low
self-esteem for the person with ADHD, affecting their ability to develop and maintain healthy
relationships (Okie, 2006; Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001)).
Moreover, a lack of healthy relationships further reinforces poor self-concept, which can
manifest as challenging behaviours in children (Robbins, 2005).
Delinquency and substance abuse. Negative peer groups can easily manipulate
adolescents with ADHD to participate in destructive peer activities like criminal behaviour,
truancy and substance abuse (Kewley, 1999; Okie, 2006; Pomerleau, 1997). The secondary
symptoms of ADHD, like low self-esteem and underachievement, can put individuals at risk for
substance abuse (Kandell & Logan, 1984). ADHD is associated with earlier onset substance
abuse symptomatolagy (Carroll & Rounsaville, 1993).
For example, Whalen and colleagues (2002) sampled 153 adolescents and found that
ADHD made one vulnerable to tobacco and alcohol use. Untreated ADHD has been associated
with a three to fourfold increase in substance misuse (Wilens, 2004). Schubiner (2005) cites that
20 to 40% of adults with ADHD have comorbid substance abuse problems. Substance abuse is
more common in those with ADHD compared to the general therapeutic population and when
the two disorders co-occur, long-term prognosis is worse (Schubiner, 2005). Many adolescents
and adults with ADHD will use substances to self-soothe and self-medicate (Duncan, Duncan, &
Strycker, 2000; Pomerleau, 1997). Wilens (2004) explains that marijuana can have a perceived
calming and focusing affect on the brain affected by ADHD that is difficult to part with.
FAMILY TREATMENT OF ADHD AND FASD 23
Communication and social skills deficits. Robbins (2005) states that the
neurobehavioural symptoms of ADHD can lead to poor socialization and communication skills
in affected individuals. Persons with ADHD have trouble discerning social cues and interpreting
body language, due to ongoing interference from symptoms such as distractibility, irritability,
over-reactivity, sensitivity, inattention, and poor self-regulation (Robbins, 2005). Children with
ADHD have a difficult time maintaining attention, listening and holding onto the thoughts
necessary for reciprocal conversation (Robbins, 2005).
Robbins (2005) also contends that children with ADHD will often attempt to self-
stimulate by provoking others. In response to sensory overload and cognitive demand, these
children may exhibit outbursts of irritable behaviour. Mate (1999) maintains that those with
ADHD experience emotional stimuli differently from their peers, which often leads to conflict
and power struggles. These challenging behaviours may repel peers who lack understanding of
their etiology. In childhood, all of these symptoms may lead to missed learning opportunities
with peers (Landau & Moore, 1991). Certain interpersonal skills, normally acquired via peer
observation, copying, practice, and feedback become threatened, putting children at further
social disadvantage as they mature into adulthood (Landau & Moore, 1991).
ADHD and school functioning. The school setting and its environmental demands can
be extremely challenging for a child with ADHD. In fact, children with ADHD are three to
seven times more likely to receive special education, experience school disruption, or repeat a
grade than the average child (Le Fever, Villers, & Morrow, 2002). Seventy-five percent of
children in special education have ADHD diagnoses (Dery, Toupin, Pauze, & Verlaan, 2005;
Forness & Kavale, 2001; Pelham & Gnagy, 1999) and 25% of children with ADHD have
learning disabilities (Ingersoll & Goldstein, 1993). Children with ADHD typically struggle with
FAMILY TREATMENT OF ADHD AND FASD 24
the ability to monitor their emotions and behaviour in a socially desirable manner (Pelham &
Gnagy, 1999). Nadeau (2005) states that:
Poor-time management skills result in chronic lateness and missed deadlines;
organizational problems lead to cluttered desks, misplaced paperwork, and difficulty in
scheduling and prioritizing tasks. Difficulties with self-regulation and need for structure
make it difficult . . . to work well independently and to complete complex, multistep
tasks. (p. 550)
This manner of dysregulation (i.e., attentional, inhibitory, emotional, strategic and organizational
deficits) often leads to adverse social and educational outcomes for the child with ADHD (Acro
et al., 2004; Douglas, 2005).
Treating ADHD
ADHD is a complex disorder; therefore, effective interventions need to address multiple
areas of concern for children and their families. The literature on ADHD is extensive, but
reveals a lack of consensus on the best approach treatment approaches (Pelham & Fabiano,
2008). Opinion is divided among those who advise the use medications alone (Abikoff, 1991),
versus those who recommend the use of psychosocial or combination approaches (Baer &
Nietzel, 1991; MTA Cooperative Group, 1999).
Pharmacotherapy. Stimulant medication is the primary treatment modality for ADHD
(Abikoff, 1991). Medication aims to enhance attention, and to reduce impulsivity and
hyperactivity (Education Publication Centre [EPC], 2008). Stimulant medication alters
neurotransmitter levels of dopamine and norepinehphrine at the synaptic level (Okie, 2006). In
1999, an American federally funded 14-month randomized trial of treatment strategies for
ADHD by the MTA Cooperative Group found that using medication to treat ADHD was superior
FAMILY TREATMENT OF ADHD AND FASD 25
to behaviour therapy. However, a 2004 follow-up study of the 1999 findings, found that the
positive effects of pharmacotherapy diminish over time (MTA Cooperative Group, 2004). In
2010, the Center for Disease Control and Prevention in the United States published a report that
66.3% of the children and youth in America diagnosed with ADHD are taking medication for
their symptoms, amounting to a total of 2.7 million children.
A more recent European study found that treating children for ADHD with a combination
of psychosocial therapy and medication was no more effective than treating them with
medication alone (van der Oord, Prins, Oosterlaan, & Emmelkamp, 2007). Yet, another study of
285 children with ADHD, found little evidence for the superiority of medication over the use of
psychosocial interventions (Hoza et al., 2005). Evans and colleagues (2001) found that larger
doses of medication are not necessarily increasingly effective in treating ADHD and that the
long-term effects of medication in childhood remain unknown.
Research indicates that while the majority of children respond positively to medication,
others can suffer side effects that make medication as a singular course of treatment controversial
(Abikoff et al., 2004; Acro et al., 2004; Okie, 2006). Since the main symptoms of ADHD do not
typically occur in isolation, certain clinicians prefer combined treatments for those with complex
subtypes (Okie, 2006).
Psychosocial interventions. Medication does not appear to normalize the entire range of
behaviour problems in ADHD on a consistent basis (EPC, 2008). The plethora of literature
focused on pharmacological treatment for ADHD often fails to include the evidence for the
benefits of psychosocial interventions (Branham et al., 2009). Pelham and Gnagy (1999) stress
that pharmacotherapy is not a panacea for treating the complexities of ADHD symptomatolagy,
but that complementary psychosocial interventions lead to the best outcomes. They state that
FAMILY TREATMENT OF ADHD AND FASD 26
“simply medicating children, without teaching them skills they need to improve their behaviour
and performance, is not likely to improve the children’s long-term prognosis” (p. 226).
Robin (1998) also believes that stimulant medication cannot adequately deal with
psychosocial symptoms alone and therefore recommends family-based interventions for working
with ADHD. Murphy (2005) also contends that while stimulant medication may ameliorate
neurobehavioural dysfunction, it fails to provide other benefits reaped from therapeutic
interventions. Psychotherapy can enhance self-esteem, social interactions, self-advocacy skills
and other behavioural and emotional concerns (Brown, 2000). The American Academy of
Pediatrics (1999) also emphasizes the benefits of psychosocial interventions in conjunction with
pharmacological treatment.
Behavioural approaches. Research studies have specifically found evidence for the
efficacy of psychosocial interventions especially behaviour management training and behaviour
therapy for treating ADHD (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004; Dopfner et al.,
2004; Pelham et al., 2005). Behavioural interventions aim to teach parents and teachers about
ADHD as a disorder, as well as how to use the principles of operant conditioning to modify
undesirable behaviour at the source (Acro et al., 2004; Fabiano & Pelham, 2003). Behaviour
training attempts to modify a child’s physical and social environment to alter their behaviour
(EPC, 2008). Adhering to learning theory notions of positive and negative reinforcement,
behaviour modification provides incentive rewards and immediate feedback for desired
behaviour, and consequences for undesirable behaviours (Fabiano & Pelham, 2003). A
behaviour assessment pinpoints what a child is doing that is problematic, while attempting to
understand its etiology and brainstorm solutions (Emerson, 2000).
FAMILY TREATMENT OF ADHD AND FASD 27
Behaviour parent training. Environmental and family influences can contribute to the
severity of ADHD symptomatolagy in children (Ingersoll & Goldstein, 1993; Robbins, 2005). If
parents do not understand that their child’s behaviours are symptomatic of their ADHD, they
tend to react to their child’s challenging behaviour with increasing frustration, coercion, anger,
and even abuse (Brown, 2000; Robbins, 2005). Parents can be educated on effective behaviour
management strategies for their children in individual or group settings (Brown, 2000).
Behaviour parent training (BPT) allows parents to learn new ways of reducing environmental
stimulation and recognizing triggers that cause stress and anxiety for their child (Edwards, 2002;
Robbins, 2005). BPT can help parents learn attachment techniques and heal strained
relationships with their child with ADHD (Johnston & Mash, 2001).
Sonuga-Barke et al. (2001) looked at two parent-based therapies in a sample of 78
children with ADHD and found that BPT helped to alleviate children’s symptoms. The authors
also found that once parents had increased confidence in their management abilities, they
experienced higher self-esteem and lower levels of stress. In turn, this reduced non-compliance
in the children. However, Chronis and colleagues (2004) found that parents are likely to drop
out of BPT if they are experiencing marital dissatisfaction, high levels of stress or depression.
The usefulness of the therapeutic alliance appears to be integral to the success of any BPT
program. In a sample of 218 children and their parents, Kazdin and Whitley (2006) found that
the quality of the therapeutic alliance correlates to greater improvements in parenting practices
then a course of BPT.
Cognitive-behavioural interventions. There is less research evidence for the efficacy of
cognitive behavioural therapy (CBT) compared to the research on behaviour modification
however CBT interventions have demonstrated improvements in ADHD symptoms in certain
FAMILY TREATMENT OF ADHD AND FASD 28
studies (Calderon, 2001; Miranda, Jarque, & Tarraga, 2006; Miranda, & Presentacion, 2000).
These gains appear both at home and at school in areas related to self-regulation, challenging
behaviour, and other ADHD related symptoms (Acro et al., 2004).
CBT teaches children with ADHD self-management techniques and problem solving
strategies to cope with their EF deficits across the lifespan (Acro et al., 2004; Murphy, 2005).
Children attempt to learn self-control via a number of activities like feelings awareness, thought
monitoring, verbal self-instruction, problem-solving strategies, thought reframing, self-
reinforcement, and self-evaluation (Lochman, Barry, & Pardini, 2003). Therapists can employ
role modeling activities as well as rehearsal and practice of strategies. Children and therapists
can also explore how thoughts, feelings, and actions affect behaviour (Wiggins, Singh, Getz, &
Hutchins, 1999).
Miranda and Presentacion (2000) found that cognitive-behavioural self-control therapy,
(including self-instructional training, modeling, and behavioural contingencies) worked well for
children in their study. This was especially true when combined with anger management
training for aggressive children with comorbid ADHD. A recent study by Branham and
colleagues (2009) found that participants in a 6-week CBT workshop experienced a significant
gain in knowledge, self-esteem and self-efficacy compared to a control group that only received
pharmacotherapy.
Another area of CBT is parent-teen mediation (Barkley, Edwards, Laneri, Fletcher, &
Metevia, 2001). Barkley et al. (2001) performed modified CBT-based parent-teen medication
with 97 families and found that 23% experienced reliable change. Families learned new
communication and problem solving skills, and developed behaviour contracts for follow-
through.
FAMILY TREATMENT OF ADHD AND FASD 29
Psychoeducational approach. Ramsay and Rostain (2005) stress the benefit of
psychoeducation in psychotherapy. They believe psychoeducation allows children and parents to
comprehend the neurobiological etiology of their condition. Brown (2000) also asserts that
children with ADHD have a right to understand their condition according to their level of
understanding. Brown also asserts that children can learn to recognize their own strengths and
limitations and better recognize how their brain works. Branham et al. (2009) found that
psychoeducation on ADHD leads to increases in self-esteem for affected individuals.
Psychoeducational approaches delivered in applicable environmental contexts are favoured in the
literature (Acro et al., 2004).
Life and social-skills training. Children with ADHD often struggle with social, life and
adaptive skills therefore assistance and education in these areas can prove useful (Bagwell,
Molina, Pelham, & Hoza, 2001). Hesslinger and colleagues (2002) showed that skills-based
training programs increase children’s self-esteem while concurrently reducing disorganized and
inattentive behaviour. Similarly, Branham and colleagues (2009) found that skills training on
topics like time management, problem solving, employment maintenance, and relationship
building tools could lead to increases in self-efficacy and self-worth. Therapists can help clients
with specific problems that arise in different social settings and help brainstorm ways to cope
with them better (Ramsay & Rostain, 2005).
In 1994, DuPaul and Stoner found that children can gain new knowledge in skills-based
training programs, but they do not always remember how to apply their training outside of
session. These authors stressed the importance of practicing new skills via role-play and
rehearsal to cater to the kinaesthetic aptitude of children with ADHD (Acro et al., 2004; Barkley
et al., 2000; Murphy, 2005). They recommend that therapists employ worksheets, stories,
FAMILY TREATMENT OF ADHD AND FASD 30
scripts, and psychodynamic activities to keep learning diverse and interesting for the same reason
(Wiggins et al., 1999).
Self-advocacy training. Self-advocacy training is another area of life skills instruction
that is important for children and families affected by ADHD (Lennox et al., 2004). Over time
service providers will change, therefore the person with ADHD and their family must become
experts in their own condition. Nadeau (2005) asserts that adolescents and adults with ADHD
must be able to communicate their strengths and challenges and communicate them clearly to
others. This degree of self-advocacy will allow persons with ADHD to obtain accommodations
necessary for success.
Strengths-based family-centred interventions. Families struggling with children and
challenging behaviour often experience high conflict, harsh and inconsistent discipline, low
monitoring of children, and a lack of social support (Henggeler, 1999). Henggeler and Lee
(2003) recommend that therapists emphasize the positive aspects of a family system during
treatment. They explain that positive focus on a family’s strengths develops rapport and
maintains relationships. Interventions should be oriented toward the family’s current specific
problems. Stoddart (1999) asserts that therapy is most beneficial when there is ongoing family
contact and collaboration.
Multimodal therapies. Klassen and colleagues (2004) suggest that treatment efficacy for
ADHD depends on the identification of individual comorbid features, the development of a
unique profile, and the implementation of a broad base of support at school, home and in the
community. In other words, Klassen et al. support a multimodal approach that encourages
diversity, collaboration, and flexibility. Many researchers contend that the best treatment for
ADHD is a multimodal approach that encompasses a wide range of interventions (Cantwell,
FAMILY TREATMENT OF ADHD AND FASD 31
1996; Edwards, 2002; EPC, 2008; Goldstein, 1996; Harris, 2000; Pelham & Gnagy, 1999;
Miranda et al., 2006). The EPC (2008) states that multimodal therapies improves academic,
parent-child, and school related concerns, as well as serves to reduce anxiety and defiance in
children. Multimodal therapies allow therapists to create an individualized plan for each family
tailored specifically to their needs, rather than using a blanket approach (Green & Albon, 2001;
Henggeler & Lee, 2003).
Multimodal therapies are strengths-based approaches that provide support, problem
solving strategies, and encouragement to reinforce clients and their abilities (Foster et al., 2009).
Therapists take a thorough family history, assess strengths and challenges, and develop treatment
goals from both the child and family’s perspective (Schoenwald et al., 2000). Initial goals centre
on parenting education, bolstering social support, and enhancing parent to community
communication (Schoenwald et al., 2000). The therapist empowers the primary caregiver with
the necessary skills and resources needed to address their child’s behaviour problems
(Schoenwald et al., 2000). Parents learn new skills to effectively monitor and discipline their
children in an incremental, realistic and productive ways (Huey, Henggeler, Brondino, &
Peckret, 2000). Youth are empowered through the learning of coping mechanisms for dealing
with family, peers, school, and their community (Henggeler, Schoenwald, Borduin, Rowland, &
Cunningham, 1998).
Medication coupled with various therapy interventions has shown improvements in adults
with ADHD. A study by Ratey, Greenberg, Bemporad, and Lindem (1992) yielded success in
treating ADHD symptomatolagy by reinforcing existing strengths and capabilities in individuals
with ADHD, while exploring new coping mechanisms for daily life. Rostain and Ramsay (2006)
found that a multimodal approach to treating ADHD in 42 patients led to significant
FAMILY TREATMENT OF ADHD AND FASD 32
improvements in ADHD symptoms, and self-reported alleviation of depression, anxiety, and
hopelessness.
Special considerations for therapy. Ramsay and Rostain (2005) caution therapists to
expect the same problems in therapy, as their clients with ADHD face in their daily lives (e.g.,
missed appointments, tardiness, forgetfulness, lack of follow-through on assigned tasks, etc.). A
client with ADHD may exhibit challenging behaviour in response to the cognitive and emotional
demands of therapy (Ramsay & Rostain, 2005).
Therapist approach and attitude. Nadeau (2005) suggests that therapists take an active
and directive stance to keep therapy sessions focused and on track, and Hallowell and Ratey
(1994) suggest that therapeutic interventions be interactive, directive, and solution-focused.
Hallowell (1995) even uses the word “coach” to define the role of the therapist working with
children and youth with ADHD. Therapists can be supportive of families through affirmation,
praise, encouragement and empathy (Harwood & Eyberg, 2004). The quality of the early
therapist-parent relationship is critical to the successful completion of family therapy (Harwood
& Eyberg, 2004).
It is also essential that a child’s family to be involved with the therapeutic process to help
the child practice skills outside of therapy sessions (Pelham & Gnagy, 1999). Skills rehearsal
and practice in the child’s natural environment reinforces learning, and maximizes the potential
for treatment efficacy (Pelham & Gnagy, 1999).
Alternatives to talk therapy. Traditional talk therapy can prove challenging for children
with ADHD who have EF deficits in communication (Portie-Bethke, Hill, & Bethke, 2009).
Researchers indicate that a creative, strengths-based, dynamic therapy style better serves the
needs of this population (Hanna, Hanna, & Keys, 1999, Portie-Bethke et al., 2009). This can
FAMILY TREATMENT OF ADHD AND FASD 33
range from individual in-session activities, to larger family or group-based experiential learning
opportunities in the outdoors (Fletcher & Hinkle, 2002). Hands-on approaches that encourage
personal strength and skill development can be more effective than behaviour treatments,
medication alone or a placebo (Edwards, 2002; Glass & Myers, 2001).
Fetal Alcohol Spectrum Disorders
Fetal Alcohol Spectrum Disorders (FASDs) are a constellation of cognitive, emotional,
and physical disabilities resultant of prenatal alcohol exposure (Malbin, 2008). FASD is an
umbrella term rather than its own medical diagnosis used to identify a continuum of lifelong
disabilities (Mela, 2006). FASDs are a consequence of alcohol-related brain pathologies that
affect specific domains of neuropsychological functioning (Mela, 2006). FASDs are the leading
cause of developmental disabilities in children (Paley & O’Connor, 2009). Despite this fact,
FASDs are largely invisible disabilities and continue to go unrecognized and undiagnosed
(Malbin, 2008).
The realm of FASD is still in its infancy (Malbin, 2008). Jones and Smith (1973) first
labelled the birth defect Fetal Alcohol Syndrome (FAS), the most severe condition resulting from
prenatal alcohol exposure (PAE), over 35 years ago. Jones and Smith recognized a specific
cluster of symptoms in children born to severely alcohol-addicted mothers that included a pattern
of characteristic facial malformations, growth deficiencies and neurodevelopmental deficits from
central nervous system damage (Hoyme et al., 2005). Malbin (2008) classifies FASDs are
neurodevelopmental disabilities with neurobehavioral symptoms.
Epidemiology. Over 50% of pregnancies are unplanned, and statistics show that five to
25% of pregnancies are alcohol exposed, depending on the timing of ingestion (Gladstone, Levy,
Nylman, & Koren, 1997; Pascoe, Kokotailo, & Broekhuizen, 1995; Tsai & Floyd, 2004). On
FAMILY TREATMENT OF ADHD AND FASD 34
average, epidemiological studies estimate prevalence rates of FASDs at 9.1 in 1000 live births
(Sampson et al., 1997). However, other studies have listed the rates as anywhere from 2 – 25%
depending on the population (Mela, 2006).
Deleterious effects of PAE. The body of clinical research on the detrimental effects of
prenatal alcohol exposure is extensive and well documented (Giarratano & Williams, 2007;
Hoyme et al., 2005). Numerous studies have documented the significant neurocognitive
deficiencies in individuals with PAE, even those who do not meet the full criteria for the FASD
spectrum (Guerri, Bazinet, & Riley, 2009; Kodituwakku, 2007; Rasmussen, 2005; Rasmussen,
Horne, & Witol, 2006; Riley, & McGee, 2005).
A study by Barr, Streissguth, Blakely, Darby, and Sampson (1990) found a significant
relationship between early maternal alcohol consumption in pregnancy and impaired fine and
gross motor skill performance in children at age four. The mothers in this study considered
themselves “social drinkers”. The study also found lower IQ levels in children exposed to
moderate levels of alcohol in early pregnancy. The authors of this study concluded that there is
no safe exposure threshold to alcohol in pregnancy, due to the potential for a variety of negative
neurobehavioural effects.
A 2008 study by Disney and colleagues of 1252 adolescents and their parents found that
prenatal alcohol exposure was associated with high levels of conduct-disorder symptoms in
children. Another study from the same year (McGee, Fryer, Bjorkquist, Mattson, & Riley, 2008)
suggested that adolescents with PAE have substantial impairments in the ability to solve
problems in daily life. Even more interesting is a 2010 study by Landgren, Svensson, Stromland,
and Gronlund, which found that adopted children with PAE from Eastern European orphanages
FAMILY TREATMENT OF ADHD AND FASD 35
retained behavioural and cognitive damage despite a radically improved post-adoptive
environment.
FASD and the brain. The brain is the most vulnerable organ to PAE (Mela, 2006).
Alcohol has a direct toxic effect on the brain and affects brain functioning, brain structure and
neurochemistry in complex ways (Malbin, 2008; Mela, 2006). Goodlett and Horn (2001) explain
that PAE can result in cell death, damaged mitochondria, altered fetal tissue development, and
gross interference in the developmental factors of the brain required for cell proliferation.
Ethanol can change neural migration routes during brain development, resulting in neuron
termination in erroneous locations and general neuronal dysfunction (Streissguth, 2001). In
animal studies, PAE reduced neurons by over 30% (Zhou, Sari, Zhang, Goodlett, & Li, 2001).
Essentially, the brain can experience overgrowth, undergrowth, gaps, tangles and changes to the
delicate balance of neurotransmitter levels when exposed to alcohol prenatally (Malbin, 2008).
These alterations render an individual with PAE susceptible to mental health disorders and
substance abuse later in life (Cordes, 2005).
PAE can affect several key brain areas responsible for intellectual functioning, motor
ability, EF and memory (Kodituwakku, 2007). Damage to the frontal cortex area of the brain
can result in smaller head circumference, reduced brain volume, problems with mood regulation
and deficits in executive functioning (Kodituwakku, 2007; O’Connor & Paley, 2006; Rasmussen,
2005; Rasmussen et al., 2006; Schoenfeld, et al., 2006). These brain differences appear to persist
into adulthood (Baer et al., 2003). Like with ADHD, EF problems are associated with vulnerable
brain development and injury (Gioia & Isquith, 2002). EF deficits are equally applicable to
children with neurological impairments from developmental origins.
FAMILY TREATMENT OF ADHD AND FASD 36
EF dysfunction impairs social and cognitive processes, which can lead to an increase in
reactive and aggressive behaviour, impulsivity and attentional problems (O’Malley & Nanson,
2007). In fact, PAE and attentional impairments are often connected (Lee, Mattson, & Riley,
2004). EF deficits manifest as impairments in learning, judgement, peer interaction, academic
and social challenges, and additional concerns. Many of these deficits remain hidden as young
children until such time that more sophisticated environments (i.e., school) which challenge the
child (Mattheis, 2007).
Magnetic resonance imaging (MRIs) of brains exposed to alcohol in utero do exhibit
distinct changes from normal brains (Spadoni, McGee, Fryer, & Riley, 2007). However, it is
important to note that the resultant brain changes of alcohol exposure in utero are not
homogeneous (Kodituwakku, 2007). These variations in severity and susceptibility are
attributed to environment-gene interaction, the timing and dosage of the alcohol ingestion, and
the mother and fetus’ metabolism (Kodituwakku, 2007). Blood alcohol concentration is linked
to the severity of potential brain injury (Maier, Strittmatter, Chen, & West, 1995).
FASD diagnosis. Chudley et al. (2005) stress that, “. . . diagnosis is essential to allow
access to interventions and resources . . . therapy and treatment” (p. 52). Misclassification results
in inappropriate care, and an increased risk of secondary symptoms (Astley & Clarren, 2000).
Health Child Manitoba (2007) adds that “a large part of the diagnostic process includes
developing strategies and interventions, specifically designed for the uniqueness of the child and
family, to help the child learn and succeed” (p. 76).
Diagnostic criteria for FASDs. After FAS was recognized as a birth defect, the term
Fetal Alcohol Effects (FAE) was created to refer to individuals with less severe phenotypes who
did not display the facial malformation and growth deficiencies associated with FAS, but who
FAMILY TREATMENT OF ADHD AND FASD 37
did display central nervous system difficulties (Hoyme et al., 2005). Streissguth (2001) states
that:
Depending on the dose, timing, and conditions of exposure as well as on the individual
characteristics of the mother and fetus, prenatal alcohol exposure can cause a wide range
of disabling conditions. Some children are diagnosable with the full FAS [Fetal Alcohol
Syndrome]; others have only partial manifestations, usually the CNS [Central Nervous
System] effects without the characteristic facial features of growth deficiency. (pp. 4-5)
The term FAE was popular but became problematic when used to label entire populations
with suspected rather than confirmed alcohol exposure (Hoyme et al., 2005). In 1996, the
National Institute of Medicine (IOM) released new criteria for medical diagnosis of the condition
previously known as FAE, including partial FAS (pFAS), Alcohol-Related Neurodevelopmental
Disorder (ARND), and Alcohol-Related Birth Defects (ARBD; Hoyme et al., 2005; Stratton,
Howe, & Battaglia, 1996; Streissguth, 2001). The IOM (1996) recommends that diagnosis occur
between ages 2-11 when there are less potential comorbid variables and better access to
background history (Stratton et al., 1996). The IOM criteria do not lay out specific parameters
for each diagnostic category, therefore some researchers consider the categories too vague
(Hoyme et al., 2005).
In 2000, Astley and Clarren published the Washington Criteria based on work with 1014
children with FAS diagnoses. The Washington criteria assigns each person with a FASD a 4-
digit code (ranging from 1111 to 4444) which reflects on a Likert scale the evident degree of
four key diagnostic features of FAS (i.e., growth deficiency, facial phenotype, CNS
damage/dysfunction, and alcohol exposure in utero). The Washington Criteria is criticized for
not including family and genetic screening in diagnosis, and for focusing too focusing too
FAMILY TREATMENT OF ADHD AND FASD 38
heavily on neurobehavioural symptoms that could be attributed to other disorders (Hoyme et al.,
2005). In the Canadian guidelines for diagnosis of FASDs, Chudley and colleagues (2005)
recommend a harmonization of the IOM criteria and 4-digit diagnostic code approaches for
multidisciplinary assessment.
FASDs and the DSM-IV-TR. Despite the relationships between FASD and mental
health problems, currently FASDs do not have a category in the current edition of the DSM-IV-
TR (APA, 2000). Mela (2006) explains that the International Classification of Disease manual,
widely used in Europe, does have a category for FASDs under “noxious influences affecting the
fetus or newborn”, but the DSM-IV-TR does not have any applicable category. Mela states that
the psychiatric community has ardently debated the inclusion of FASDs in the DSM-IV-TR. As
it stands, psychiatrists cannot make a diagnosis on the FASD continuum, even though diagnosis
is the key to effectual intervention, prevention and management.
Since 90% of people with FASDs have comorbid mental health issues, mental health
professionals are frequently working with people on the FASD spectrum without knowing it
(O’Malley & Nanson, 2007). In the absence of the ability to diagnose patients with a FASD,
patients typically receive a comorbid DSM-IV-TR diagnoses that does not reflect underlying
neurological dysfunction (APA, 2000; Malbin, 2008). Mela (2006) contends that FASDs
produce measurable cognitive and behavioural manifestations that can be classifiable as
psychiatric diagnoses. Not having FASDs in the DSM-IV-TR serves to keep the population
hidden in North America (Malbin, 2008).
Multidisciplinary assessments. The Canadian guidelines for FASD diagnosis advocate
for the use of multidisciplinary assessment (Chudley et al., 2005). Malbin (2008) states that
multidisciplinary assessments are crucial to proper identification of FASDs, since these types of
FAMILY TREATMENT OF ADHD AND FASD 39
assessments address the multiple variables that contribute to brain dysfunction. A
multidisciplinary assessment of a FASD allows for comprehensive views of client functioning
and serves as a blueprint for accurate intervention. Hoyme and colleagues (2005) suggest that,
“FASD must always be a diagnosis of exclusion” (p. 43), which is why a multidisciplinary
assessment is so integral to accurate diagnosis of FASD.
Absence of identification. Persons with FASDs experience negative life outcomes in the
absence of proper assessment, diagnosis and treatment for their FASD (Hoyme et al., 2005;
Novick & Streissguth, 1995). Without proper diagnosis, children are punished for
neurobehavioral deficits like inconsistent memory and hyperactivity, and frustration increases for
both children and caregivers (Malbin, 2008).
Cited as reasons for under-diagnosis are: (a) the stigma surrounding the disorder, (b) the
difficulty in confirming PAE in pregnancy, and (c) the inability of many clinicians to recognize
the symptoms of FASDs (i.e., especially in less severe cases; Hoyme et al., 2005; Novick &
Streissguth, 1995). Birth mothers are often more accurate in their reporting of alcohol ingestion
retrospectively, rather than during their pregnancy, when they are more likely to underreport
ingestion or deny it all together (O’Connor & Paley, 2009). To obtain an accurate diagnosis on
the FASD continuum, there has to be confirmation of PAE from a reliable source (Chudley et al.,
2005).
Symptoms of FASD. There is no singular phenotype for FASDs, since alcohol affects
the brain in a variety of ways (Mabin, 2008). However, there are general symptoms of FASDs
divided into two categories called primary and secondary symptoms.
Primary symptoms. Primary symptoms derive from brain dysfunction and secondary
symptoms are the result of poor lifelong accommodations. Malbin (2008) refers to primary
FAMILY TREATMENT OF ADHD AND FASD 40
symptoms as “learning, thinking, physical responses to the environment and other behavioural
symptoms associated with differences in brain structure and function” (p. 29). She explains that
neurological differences often appear as: (a) slower processing speed, (b) problem storing and
retrieving information, (c) difficulty forming associations, (d) trouble with abstraction, (e)
difficulty generalizing, (f) difficulty seeing future steps and outcomes, (g) disconnections
between words and actions, and (h) the inability to maintain perspective. She stresses that these
differences are not behavioural problems but symptoms of a disability.
Bookstein, Barr, Press, and Sampson (1998) define the behavioural profile of individuals
with FASD as including:
. . . problems with communication and speech (e.g., speaking too much and/or too fast
and interrupting others), difficulties in personal manner (e.g., clumsiness,
disorganization, and losing or misplacing things), emotional lability (e.g., rapid mood
swings and overreacting), motor dysfunction (e.g., difficulty playing sports), poor
academic performance (e.g., poor attention span and difficulty completing tasks),
deficient social interactions (e.g., lack of awareness of consequences of behavior and
poor judgment), and unusual physiologic responses (e.g., hyeracusis, hyperactivity, and
sleep disturbances). (p. 43)
In addition to this behavioural profile, individuals with FASDs often demonstrate
perseveration, though rigidity, sensory defensiveness, cognitive delays, EF malfunctioning, poor
problem solving, impulsivity, low or high arousal, boundary confusion, lack of empathy, and
irritability (Coggins, Olswang, Olson, & Timler, 2003; Kelly, Day, & Streissguth, 2000; Malbin,
2008; Novick & Streissguth, 1995; Semrud-Clikeman & Ellison, 2009; Streissguth, 2001;
Streissguth et al., 1998).
FAMILY TREATMENT OF ADHD AND FASD 41
Developmental dysmaturity is common in individuals with FASDs. An 18-year-old with
a FASD may have the expressive language abilities of a 20-year-old, but the emotional maturity
of a 6-year-old (Malbin, 2008). Additionally, individuals with FASDs tend to have inconsistent
patterns of learning and behaviour. Malbin (2008) explains, “. . . some days they meet or exceed
levels of expectation. This may result in random reinforcement of actually inappropriately high
levels of expectation” (p. 57).
Secondary symptoms. Secondary behavioural characteristics are “those behaviours that
develop over time as a result of chronic frustration and failure. They protect from pain and
reflect a poor fit between the needs of the person and his or her environment. These are
preventable and resolvable” (Malbin, 2008, p. 29). Secondary symptoms include trouble with
the law as victim or offender, school disruption, mental health problems, substance abuse,
confinement, inappropriate sexual behaviour, challenging behaviours, emotional reactivity, flat
affect, low self-esteem, isolation, issues with employment and even suicide (Clark et al., 2004;
Malbin, 2008). Various longitudinal studies support the prevalence of persistence of these
symptoms (Clark et al., 2004; Streissguth, Barr, Kogan, & Bookstein, 1996). However, Malbin
(2008) insists that secondary symptoms can be avoided with accurate identification and supports.
Strengths and illusions of competency. Malbin (2008) states that despite the challenges
that FASDs bring, individuals with a FASD concurrently possess unique strengths, skills, and
talents that set them apart from unaffected peers. Unfortunately, these abilities “may erode over
time when deficits are the focus of attention” (p. 34). Building on strengths increases self-
esteem and fosters resiliency. Sometimes however, these strengths can mask the presence of a
disability all together (Malbin, 2008). For example, Mattheis (2007) explains that persons with
FASDs have stronger expressive language capabilities than receptive comprehension skills,
FAMILY TREATMENT OF ADHD AND FASD 42
which leads outsiders to assume an individual is more competent than their true level of
functioning. Children learn over time how to compensate for their disability and can appear to
understand concepts even when they do not (Malbin, 2008). Individuals with FASDs tend to
have an uneven scatter of abilities and large gaps between IQ levels and adaptive skill
functioning (Clark, Lutke, Minnes, & Ouelette-Kuntz, 2004; O’Malley, 2007).
Protective factors. Streissguth et al. (1996) cite eight protective factors against mental
illness and other secondary symptoms for those with FASDs. They are: (a) living in a stable
home for 72% of one’s life, (b) being diagnosed before the age of six, (c) never experiencing
personal violence, (d) staying in each living situation for more than 2.8 years, (e) experiencing a
good quality home from the ages of 8-12, (f) eligibility for disability services, (g) having a
diagnosis of FAS, and (h) having one’s basic needs more for at least 13% of life. Unfortunately,
many of these require early identification and interventions, which are not usually the case for
most individuals with FASDs.
FASD and mental health issues. Children of mothers who abuse substances are at
increased vulnerability for socio-emotional problems that persist throughout the lifespan
(Conners et al., 2003; Semrud-Clikeman & Ellison, 2009). O’Connor and Paley (2009) contend
that the neurocognitive problems associated with FASD lead to a range of psychosocial
dysfunction. PAE appears to be its own independent and significant risk factor for early onset
psychopathology. O’Connor and Paley believe this vulnerability transmits via genetic
susceptibility, temperamental deficits from PAE, and the direct effect of alcohol on brain
development in itself. In a number of longitudinal studies, PAE correlates to a higher risk of
adverse long-term outcomes in the realms of mental illness and psychosocial adjustment
(Streissguth et al., 1998). Streissguth (2001) states that there is a need for further research
FAMILY TREATMENT OF ADHD AND FASD 43
regarding the relationship between children’s emotional adjustment and PAE, so that clinicians
may spot the signs of CNS dysfunction earlier. Mills, McLennan, and Caza (2006) believe that
early involvement of mental health clinicians for persons with FASDs can ameliorate mental
health outcomes. Unfortunately, research indicates that children with FASDs access fewer
mental health providers that children with other disorders (i.e., ADHD; Mills et al., 2006).
Comorbid psychiatric issues. A number of clinical studies with sample sizes from 23 to
8621 individuals have linked FASDs and PAE in children with a host of mental illnesses and
mental health concerns. For example, FASDs and PAE have been linked with reactive
attachment, anxiety, irritability, ODD, ADHD, social problems, mood disorders, conduct
disorder, delinquency, mania, anxiety, and disruptive behaviours (Burd, Klug, Martsolf, &
Kerbeshian, 2003; D’Onofrio et al., 2007; Fryer et al., 2007; Leech, Larkby, Day, & Day, 2006;
Lemola, Stadylmayr, & Crob, 2009; O’Connor, 2001; O’Connor, Kogan & Findlay, 2002;
O’Connor et al., 2006; O’Connor & Paley, 2006; O’Connor, Sigman, & Kasari, 1992; Sayal,
Heron, Golding, & Edmond, 2007; Roebuck, Mattson, & Riley, 1999; Schoenfeld, Mattson, &
Riley, 2005; Steinhausen & Spohr, 1998; Steinhausen, Willms, Winkler Metzke, & Spohr, 2003;
Walthall, O’Connor, & Paley, 2008).
O’Connor and colleagues (2002) looked at 23 children with PAE from ages 5-13 and
concluded that 87% met the criteria for a psychiatric disorder, 61% for a mood disorder, 26% a
major depressive disorder, and 35% for bipolar disorder. Fryer and colleagues (2007) found that
97% of the small cohort of children with PAE in their study met the criteria for at least one Axis
I diagnosis of the DSM-IV-TR versus 40% of the control group (APA, 2000). Unfortunately,
these two studies (O’Connor et al., 2002; Fryer et al., 2007) are limited by their small sample
sizes; however, Walthall, O’Connor, and Paley (2008) looked at 130 children with and without
FAMILY TREATMENT OF ADHD AND FASD 44
PAE and found that mood disorders were significantly higher in those with PAE. Even more
striking is a study by Streissguth and colleagues (1996) which looked at 400 adolescents and
adults with FASDs. The authors found that over 90% of their population had mental health
problems.
Sayal, Heron, Golding, and Edmond (2007) performed a large longitudinal study of
12,678 pregnant women and the effect of PAE on the mental health of their offspring. The
researchers kept records of drinking patterns in the first 18 weeks of pregnancy and mental
health outcomes were measured in the children at two stages of early childhood. The results
demonstrated that consuming less than one alcoholic beverage per week during the first trimester
of pregnancy could be associated with clinically significant mental health problems in female
offspring at ages 4 and 8 years.
Depression. Children with PAE seem particularly sensitive to developing some form of
childhood depression due to their compromised ability to regulate their emotions in infancy
(Olson, O’Connor, & Fitzgerald, 2001). It appears that the greater the levels of PAE, the higher
the manifestation of lifelong irritability and depressive symptomatolagy in the children
(O’Connor & Kasari, 2000; O’Connor & Paley, 2006; Lemola et al., 2009). Olson and
colleagues (2001) affirm that “. . . children prenatally exposed to alcohol . . . are particularly
vulnerable to depression and acquiring negative self-cognitions” (p. 283). The occurrence of
depression in children with PAE is as high as 19%, compared to the prevalence norm of 1%
(O’Connor & Paley, 2006). Streissguth (2001) asserts that “feelings of worthlessness, anger,
depression, and panic as well as suicidal ideation are typical of young men with FAS” (pp. 235-
236).
FAMILY TREATMENT OF ADHD AND FASD 45
Interestingly, paternal emotional support to mother and child seems to be a protective
factor for depression in children with a FASD. However, in one study by Connors et al. (2003),
over 30% of children with a FASD never saw their fathers, and only 15% of the children saw
their father once or twice a year.
Behavioural disorders and substance abuse. Adolescents and adults with FASDs
typically struggle with behavioural disorders and other forms of aggression and externalizing
behaviours (Alati et al., 2006; Alati et al., 2008; Barr et al., 2006; Boer et al., 2003; Famy,
Streissguth, & Unis, 1998; Huggins, Grant, O’Malley & Streissguth, 2008; Spohr, Willms, &
Weinhausen, 2007; Streissguth et al., 1996). Walthall and colleagues (2008) believe that PAE
often directly leads to the development of ODD, conduct disorder, and ADHD. ADHD is the
most common mental health issues in children with FASD (Premji, Benzies, Serrett, & Hayden,
2004). D’Onofrio et al. (2007) associated PAE with conduct disorder in their study of 8621
children aged 4 to 11.
Unsavoury peers can easily manipulate a person with a FASD, who lack social
understanding and maturity, into performing socially undesirable behaviours (Clark et al., 2004).
Individuals with PAE are three times more likely to display delinquent behaviour that their same-
aged peers and are overrepresented in psychiatric samples, juvenile detention centres, and
correctional settings (Burd, Selfridge, Klug, & Juelsom, 2004; Conry & Fast, 2000; O’Connor,
McCracken, & Best, 2006; Roebuck et al., 1999). Schoenfeld et al. (2005) state that those with
PAE have reduced levels of moral maturity compared to their non-exposed peers. Since
individuals with FASDs have difficulty understanding the meaning of others’ behaviour, can
develop hostile attribution bias to non-threatening social situations, putting them at further risk
for delinquent behaviour (Dodge, 2006). Due to their vulnerability to mental health problems,
FAMILY TREATMENT OF ADHD AND FASD 46
individuals with FASDs are at greater risk for substance abuse (Clark et al., 2004). Streissguth et
al. (1996) found that 30% of their sample of 400 people with FASDs had substance abuse
problems.
Attachment disruption and negative affect. A few studies have examined the relationship
between PAE and its impact on attachment and children’s moods and temperament. In their
study on the association between PAE and insecure attachment, O’Connor, Sigman, and Brill
(1987) found that the majority of infants whose mothers drank heavily in pregnancy displayed
insecure attachment. O’Connor and colleagues (1992) yielded similar results in through their
observation that infants whose mothers drank heavily in pregnancy have increased levels of
negative affect which make them less responsive to stimuli and less likely to attach securely to
caregivers. Kovacs and Devlin (1998) also showed that children with FASDs and PAE have
increased negative affect, temperamental impairments and emotional regulation problems.
More recently, O’Connor, Kogan and Findlay (2002) found that 80% of children
moderately to heavily exposed to alcohol in utero display insecure attachment, versus 36% of a
lightly exposed group. Olson and colleagues (2001) also show that caregivers find infants with
PAE and negative affect confusing and hard to mange. They state that caregivers seem less able
to attach securely to children with PAE, which leads to high levels of negative parent-child
interactions and mental health problems. In both these studies, PAE appears to predispose
children to negative affect and low coping skills yielding the children less emotionally resilient
and prone to mental health problems.
Childhood trauma, neglect and abuse. Child development research has shown that
multiple traumatic events (i.e., abuse, neglect) can cause relationship disturbances, language and
cognitive difficulties, mood and behaviour dysregulation and socio-emotional problems in
FAMILY TREATMENT OF ADHD AND FASD 47
children (Putnam, 2006). Trauma can alter the development of the body’s critical-stress
response system, known as the Hypothalamic-Pituitary-Adrenal (HPA) axis (Putnam, 2006;
Teicher et al., 2003). Putnam (2006) explains that HPA axis malfunctions can prevent a child
from properly controlling their frustration in response to various degree of sensory dysregulation.
Children become unable to self-regulate their affective states and manage their behaviour.
Each area of the brain must experience the proper amount of input to develop in a healthy
way (Perry 1999; 2002). If sensory input is chaotic, inconsistent, threatening, and
overwhelming, brain dysfunction will occur as well as psychological disturbances (Van der
Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Trauma and neglect make it difficult for the
developing brain to develop properly whereas healthy attachment modulates stress and leads to
self-regulation (Barthel & Nickel. 2009).
PAE and childhood trauma. Children with PAE often experience frequent abuse and
pervasive neglect in their biological homes (Streissguth et al., 1996). Henry, Sloane and Black-
Pond (2007) assert that the comorbidity of PAE and childhood trauma can drastically alter
normal child development. Connors et al. (2003) conducted a study of 4084 children and their
mothers and found that over 57% had been abused by a parents, and over 73% of the mothers
had been their own victims of abuse. In a study by Connor and colleagues (2003), over 59% of
the children with a FASD had witnessed domestic violence. Maternal stressors like substance
abuse, poor financial resources, unstable housing, legal problems, mental health issues, and a
lack of social support all further contribute to the problem (Connors et al., 2003).
Children with PAE and trauma display more severe neurodevelopmental limitations than
those with trauma alone including deficits in language, memory, and visual processing, as well
as motor skills and attention (Henry et al., 2007). The accumulation of risks and vulnerability
FAMILY TREATMENT OF ADHD AND FASD 48
factors are the most damaging to children (Connors et al., 2003). Bathel and Nickel (2009) state
that stress and trauma enhance the deficits associated with FASDs, since cortisol further destroys
already sensitive brain cells from PAE. PAE and trauma together can affect two core
developmental processes: (a) the neurophysiological growth of the brain, nervous system, and
endocrine system, and (b) the psychosocial development, personality formation, and social
conduct capacity for relationships (Henry et al., 2007).
Brain imaging has shown that brains affected by FASD and by trauma show striking
similarities. DeBeillis and VanDillen (2005) looked at 274 children from ages 6 to 16 with
moderate to severe trauma histories and found that 40% also had a FASD. Researchers have
begun to study the link between the CNS abnormalities of traumatized children and those with
FASD via magnetic resonance imaging (MRI; DeBeillis & VanDillen, 2005; Riley, McGee, &
Sowell, 2004).
FASDs and the educational system. FASDs affect a number of physiological and
emotional aspects of functioning that result in problems with traditional education. Streissguth
and colleagues (1996) found that 60% of their sample had disrupted school experiences. FASD
affects abstract thought, receptive communication and comprehension, selective attention,
attending, self-image, memory, behaviour, social communication, impulsivity, and poor
judgement (Streissguth, Bookstein, Barr, Press, & Sampson, 1998). These deficits impair
learning and academic success and co-occur with learning disabilities (Duquette, Stodel,
Fullerton, Hagglund, 2006).
FASDs and the justice system. Streissguth et al. (1996) state that 60% of individuals
with FASDs have been in trouble with the law. Moore and Green (2004) assert that individuals
with FASDs are at a gross disadvantage when embroiled in any aspect of the legal system. The
FAMILY TREATMENT OF ADHD AND FASD 49
cognitive deficits and organic brain damage associated with FASDs are not always outwardly
observable. The authors note that the frontal lobe area of the brain, responsible for regulating
conduct and social behaviour, is often impaired in those with FASDs, resulting in impulsivity,
fearlessness, and lack of inhibition. Individuals with FASDs are vulnerable to false confessions,
and interrogation susceptibility (Beail, 2002; Clarke et al., 2004).
FASDs and the impact on the family. Studies show an increase in psychosocial
problems in families affected by FASDs (Lach et al., 2009). Social support can be low, and rates
of depression and chronic health conditions are higher than normal (Lach et al., 2009).
Professionals need to consider caregiver issues and their impact on child well-being. Brown and
colleagues (2004) express that caregivers require a large degree of social and professional
support, as well as a better understanding of FASDs and behaviour management skills.
Treating FASDs
Literature for the treatment of FASDs is still in its infancy (Malbin, 2008; Schwartz,
Garland, Harrison, & Waddell, 2006; Zevenbergen & Ferraro, 2001). Although there is
extensive research on the teratogenic effects of alcohol on the fetus, clinical research on effective
research-based interventions for children with FASDs is limited (Bohjanen, Humphrey, & Ryan,
2009; Caley, Shipley, Winkelman, Dunlop, & Rivera, 2006; Premji et al., 2004). In fact, Premji
et al. (2004) looked at 40 peer reviewed journal article as 23 grey literature articles and found
limited reliable data from which to recommend superior interventions for FASDs.
The majority of information on the management and treatment of FASDs derives from
the practical wisdom of parents and clinicians gleaned through trial and error (Bertrand, 2009;
Premji et al., 2004). Although these techniques may work well with those with FASDs, they
lack scientific foundation. Many of the strategies employed by professionals for FASDs are
FAMILY TREATMENT OF ADHD AND FASD 50
based on research from comparable disciplines (e.g., ADHD, developmental disabilities,
traumatic brain injury, and neurobehavioural disorders) rather than on FASD specifically
(Bertrand, 2009). A number of experts in the field of note that there is a dire need for rigorous
scientific studies on interventions for persons with FASDs (Coles, 2003; O’Malley &
Streissguth, 2003; Roberts & Nanson, 2001). In spite of the lack of research, psychologists like
Knight (2008) argue that psychotherapy for individuals with FASDs is vital and productive as it
creates a sense of safety, and teaches individuals how to maintain healthy relationships and
develop coping mechanisms for daily life.
Bertrand (2009) cautions that FASDs are heterogeneous conditions in nature and severity,
therefore services need to be equally diverse by considering environmental, behavioural and
neurological deficits as well as family functioning. Paley and O’Connor (2009) explain that a
FASD diagnosis is not sufficient in itself to direct professionals to appropriate treatment
interventions.
Pharmacotherapy. Medication can be used with patients to reduce comorbid symptoms
such as disruptive behaviour problems, mood disorders, and substance abuse disorders (Famy et
al., 1998; O’Connor et al., 2002; Burd et al., 2003, Burd et al., 2007; Walthall et al., 2008).
However, empirical support for medication and persons with FASDs is very limited (O’Connor
& Paley, 2009).
Psychosocial interventions. When assisting individuals with FASDs and comorbid
mental health issues, several modified psychosocial interventions may work to improve some of
the core deficits associated with the disorder (Benson, 2004; Davis et al., 2008; Schwartz et al.,
2006). Novick and Streissguth (1995) believe that individual therapy within a family context can
be effective if treatment is specialized, directive, structured, and dynamic, and considerate of
FAMILY TREATMENT OF ADHD AND FASD 51
neurological deficits. Estenson (2003) endorses sustained low-intensity psychotherapy for
persons with FASDs.
Davis, Barnhill and Saeed (2008) also believe that treatment should focus on long-term
management and containment of functioning in the client, as numerous crises and relapses are
liable to occur in this population. The authors recommend community-based interventions that
utilize multimodal approaches. Cooperative services provided by a team of individuals can assist
a person with a FASD, and their family, with access to community resource referrals, prevention,
outreach and advocacy services, as well as crisis care.
Ongoing support maximizes success and retention, and allows new learning to transfer to
long-term memory through repetition (Davis et al., 2008). Early removal of supports often
invites an overall family for their client’s system failure (Moore & Green, 2004). Therapists
need to act as an “auxiliary brain” for their clients and to understand that the memory of a person
with a FASD under recall is fluid (O’Malley, 2007). The specialized needs of the client warrant
and necessitate an individualized plan (Malbin, 2008).
Early intervention. Recommendations for early intervention in FASDs are prevalent in
the literature (Morrissette, 2001; Streissguth, 2001; Streissguth et al., 1996). Early interventions
can target developmental, psychosocial, or medical domains and prevent the development of
secondary symptoms that negatively affect the quality of life for individuals with a FASD
(Guralnick, 1997). Clinical research evidence for early intervention is strongest in the realms of
cognitive impairment, language disorders, and autism spectrum disorders (Smith, Eikeseth,
Klevstrand, & Lovaas, 1997; Vorgraft, Farbstein, Spiegel, & Apter, 2007). Even in these cases,
improvements are deficit specific and children remain developmentally delayed overall. This
suggests that although these disabilities are permanent, improvements in certain areas are
FAMILY TREATMENT OF ADHD AND FASD 52
possible. Unfortunately, the important window of opportunity for early intervention is often
missed and children remain untreated until their teens or adulthood (O’Connor & Paley, 2009).
Behaviour parent training. Brinkmeyer and Eyberg (2003) assert that behavioural
parent training (BPT) is the single most effective method for ameliorating significant
externalizing behaviour problems in children. BPT’s efficacy is evidence-based for children
with conduct problems and oppositional behaviour (Eyberg, Nelson, & Boggs, 2008; Kazdin,
1997; McMahon & Forehand, 2003). BPT combines consistent discipline with conditional
reinforcement for maximum efficacy (Shanley & Niec, 2010). Therapists using BPT teach
parents new skills through various feedback techniques, including modeling, reinforcement, and
correction (Shanley & Niec, 2010).
For the caregiver of a child with a FASD, the struggle to attain and maintain a positive
parental attitude and to find and use effective parenting skills is especially difficult (Paley,
O’Connor, Frankel, & Marquardt, 2006). Parents of individuals with FASDs benefit from
receiving both relationship focused, and behaviour–oriented intervention programs (Bertrand,
2009). O’Connor and Paley (2006) found that parenting skills and abilities could have some
affect on the behavioural symptoms of PAE. They explain that enhancing the parent-child
relationship should be a critical component of all FASD intervention approaches.
Cognitive-behavioural interventions. CBT interventions need to be adapted and
specifically tailored to each individual with a FASD (Novick & Streissguth, 1995). Strategies
that require cause and effect understanding are not useful, nor are approaches based on linking
concepts and generalization (O’Malley, 2007). However, O’Malley (2007) suggests that with
consistency, persistence and repetition, a person with a FASD can make some connections
between their actions and negative consequences. Teaching specific rules and expectations for an
FAMILY TREATMENT OF ADHD AND FASD 53
individual situation is more effective than assuming a client can learn from theory and apply it
outside of session (Novick & Streissguth, 1995).
Caregivers also need to work on altering their cognitions and attitudes about the meaning
of their children’s behaviour. Therapists can help parents to reframe their understanding of
behaviours as a symptom of the child’s neurodevelopmental disability (Malbin, 2008). This
increases parental feelings of self-efficacy and reduces stress, which in turn strengthens the
parent-child relationship (Bertrand, 2009). Research suggests that the maltreatment of children
with disabilities is often associated with a lack of understanding of what the child can truly
achieve (Vig & Kaminer, 2002).
Psychoeducational interventions. Bertrand (2009) states that targeted psychoeducational
programs that address FASDs can remediate certain deficits of the disorder. Family education
can reduce fears, by offering realistic expectations for treatment response and equipping family
members with coping tools (Bertrand, 2009; O’Malley, 2007). Bertrand (2009) stresses that
individuals with FASDs and their families must receive education on FASDs, their behavioural
symptoms and common comorbidities. The individual with a FASD is entitled to a clear
understanding of their condition delivered in comprehensible terms. Understanding FASDs
allows families to develop appropriate goals and expectations for therapy (Green, 2007).
Self-regulation and adaptive life skills training. Therapy time devoted to enhancing life
skills, and learning self-regulation strategies can lead to better quality of life for the person with
a FASD (Bertrand, 2009; Novick & Streissguth, 1995). In 2008, Walthall and colleagues found
that the social skills training could ameliorate the effects of PAE. Examples of techniques in this
area are relaxation training to reduce tension and anxiety, progressive muscle relaxation, anger
management training, and imagery work (Benson & Havercamp, 2007; Foxx, 2003). Therapists
FAMILY TREATMENT OF ADHD AND FASD 54
can also help the person with a FASD recognize their physical and emotional indicators of
distress and teach them strategies to seek assistance (Malbin, 2008). Training and practice in
social behaviours like recognizing cues, positive communication, and understanding
indiscriminate social behaviour is also valuable (Streissguth & O’Malley, 2000).
Possible topics for caregivers can include tips for behaviour management, effective
supervision and successful structure for the person with a FASD (Moore & Green, 2004;
Morrissette, 2001). Helping parents learn antecedents or triggers of challenging behaviour can
prevent problems in the future by way of making accommodations for their child (Bertrand,
2009). In addition, assisting parents to create timetables and schedules, or making picture charts
for desired behaviour is valuable (O’Malley, 2007). Another area of adaptive training is teaching
vocational skills to help a person with a FASD to find gainful employment; an important step
toward building a sustainable social network and living independently (O’ Connor & Paley,
2009).
Environmental accommodations. Since some of the protective factors for children with
FASDs include nurturing caregivers, appropriate structure and environmental stability, useful
interventions for caregivers can develop from this framework (Streissguth et al., 1998).
Environmental adaptations can prevent or remediate secondary symptoms by providing the
person with a FASD a “good fit” (Malbin, 2008, p. 68). Henry and colleagues (2007) explain
that:
A brain-based paradigm acknowledges the etiologies of challenging behaviour are rooted
in poor executive functioning, cognitive inflexibility, limited social communication,
deficits in language processing, affect dysregulation, and traumatic stress. These children
most often do not respond to typical models of traditional disciplines. (p. 106)
FAMILY TREATMENT OF ADHD AND FASD 55
Malbin emphasizes that individuals with FASDs need support throughout their life to
assure that they achieve their full developmental potential. Adults can adjust their expectations,
and recognize slower processing speeds in children with FASDs by providing extra time and
patience (Malbin, 2008). Individuals with FASDs benefit from minimal sensory overload in a
calm environment free of excessive demands (Riley et al., 2004). Healthy Child Manitoba
(2007) recommends the use of visual versus auditory strategies for learning. They state that the
“use of visual language to enhance comprehension and retention of learning as students with
FASD are often visual learners and possess visual processing strengths” (p. 19).
Multimodal therapy. O’Malley (2007) believes that treatment of FASDs requires a
multimodal, flexible approach that incorporates new strategies on a continuing basis. O’Malley
advocates a technically eclectic approach that draws on all approved recommendations for
working with those affected by FASDs. Davis et al. (2008) state that comprehensive treatments
combining all possible treatment modalities is best practice for treating FASDs (i.e.,
psychotherapy, parent training, and environmental accommodations).
Strengths-based family-centred interventions. Family-centred approaches have led to
improved outcomes in those with neurobehavioral conditions and many researchers and experts
in the field of FASDs stress the importance of working directly with the family of a person with
a FASD to maximize treatment value (Vargas & Prelock, 2004).
Empirical support. Family-centred care is rooted in health and social policy, especially
in regards to disability services (Dempsey & Keen, 2008; Dunst, Boyd, Trivette, & Hamby,
2002). Research evidence has shown significant positive correlation between parent perception
of family-centred strength-based approaches and their own self-reported levels of well-being,
empowerment and satisfaction with the therapeutic process (Dempsey & Dunst, 2004; King et
FAMILY TREATMENT OF ADHD AND FASD 56
al., 1999). This is an important finding considering research evidence correlating child
behavioural problems and negative parental emotional well-being is well cited (van Schie,
Siebes, Ketelaar, & Vermeer, 2004). In general, building on individual and family strengths is
correlated to increases in self-esteem (Healthy Child Manitoba, 2007).
General therapeutic approach. Madsen (2009) advises that therapists act as
“appreciative allies helping families envision and develop desired lives with the active support of
their local communities” (p. 104). King, King, Rosenbaum and Goffin (1999) agree and state
that “services are most beneficial when they are delivered in a family-centered manner and
address parent-identified issues such as the availability of social support, family functioning, and
child behaviour problems” (p. 41). All interventions should centre on sincere dialogue with
families, respecting that the family is in the best position to determine their child’s needs (Dunst,
2002). The caregivers of a person with a FASD are the most permanent forces in the child’s life
and are in the best position to be the child’s constant for support, understanding, and advocacy
throughout the lifespan (Dempsey & Keen, 2008; Dunst et al., 2002; Vargas & Prelock, 2004).
Booth and Booth (1993) assert that a worker’s values and attitudes toward parents are just
as important as their skills and knowledge. They advise that workers use observation and
creativity to help parents become aware of their strengths. Family-centred approaches focus on
the primary importance of the parent/client-to-professional relationship through one-on-one
modeling, coaching, mentorship and advocacy (Dempsey & Keen, 2008; Moore & Green, 2004;
Novick & Streissguth, 1995). Ory and Dykstra (2007), psychologists who specializes in working
with people with developmental disabilities and challenging behaviours from a family-centred
strengths-based approach, outline the role of therapists as such:
FAMILY TREATMENT OF ADHD AND FASD 57
First, our role is to form a positive relationship with the person and understand who he is
trying to be. Then we lead, model, and reward the persons existing coping skills, building
on his spontaneous interests and personal attachments so as to improve his interactions.
This requires strategies for leading, guiding, and training people to cope. (p. 6)
Collaborative helping model. One specific strength-based family-centred model, useful
for therapy with individuals and families affected by FASDs, is the collaborative helping model
(CHM). Madsen (2009) outlines the CHM intervention principles as: (a) building a foundation
for client engagement, (b) helping clients envision preferred directions in life, (c) helping clients
identify elements that may constrain and sustain their development of preferred life directions,
(d) shifting relationships to enhance sustaining elements, and (e) developing community support
to enact preferred lives.
Selekman (2010) states that all involved family members need time to share their
problems, expectations, and self-generate treatment goals and attempt their own solutions.
Selekman recommends separate time with parents and children to form separate goals. Relating
to the adolescent on their level is necessary for treatment effectiveness. Selekman suggests
empathizing with the youth that they are in therapy, and offering to help them work better with
their family to reduce stress. Therapists can assist families to realize their own resourcefulness.
Bernstein (1996) recommends a focus on relationship building and raising self-esteem.
It is also important to focus time in therapy to building the connection and attachment
between the youth and their caregivers (Selekman. 2010). Interventions to strengthen this bond
can include communication exercises, empathic listening exercises, and generating ideas for
quality time together. Selekman (2010) affirms that the stronger the bond between youth and
caregivers, the less vulnerable they are to peer deviancy and self-destructive behaviour.
FAMILY TREATMENT OF ADHD AND FASD 58
Psychodynamic strategies. Role-play and rehearsal are creative ways of teaching and
practicing skills within a kinaesthetic modality that caters to the needs of the client with a FASD
(Novick & Streissguth, 1995). Therapists can role-play triggering events with a client in-session
to make the learning concrete and situational rather than abstract. The client can rehearse
superior responses and strategies that will serve them better in similar real-life scenarios
(Estenson, 2003). Life coaching of this kind can offer ongoing real-time reflection on events and
choices as they occur, all while brainstorming the likely outcomes of choices and alternative
options (Estenson, 2003). It is important to note that success is dependent on sufficient
rehearsal, so that new learning ingrains in long-term versus short-term memory (Novick &
Streissguth, 1995). O’Malley (2007) suggests complimenting all interventions for FASDs with
indirect non-verbal techniques like art, guided play, and drama therapy where clients can express
themselves without words.
Another psychodynamic approach is adventure therapy, or group experiences in
residential outdoor recreational facilities (Weinberg, Siwowska, & Hellemans, 2008). These
programs can provide a stable and predictable environment where behavioural interventions can
take place and include training in life and vocational skills in a context that fosters independence
and optimal functioning (Davis et al., 2008).
Substance misuse counselling. Interventions can address prevention, education, and
alternative options to using substances (Alati et al., 2008; Boer et al., 2003). Cook, Kellie, Jones,
and Gossen (2000) recommend that substance use education for persons with a FASD cover the
effect of substances on the body and the criminal implications of substance use. Malbin (2008)
suggests that treatment plans be concrete, remain extremely simple and build on strengths.
FAMILY TREATMENT OF ADHD AND FASD 59
Language should be positive not negative, and tell that person what “to do” rather that what “not
to do”.
Rathburn (1996) advocates that substance misuse counselling should focus more on
physical interventions for stress relief, tactile stimulation, music, and guided relaxation.
Individuals with FASDs do not fully understand the implications of contracts or agreements that
rely on cause and effect thinking or forethought. These types of interventions will set the
individual up to fail from inception. Dishion and Kavanaugh (2003) claim increased parental
monitoring can also reduce adolescent substance abuse.
In terms of the emotional side of substance use, Bernstein (1996) suggests reframing for
adolescents that their substance abuse has been a coping mechanism to avoid pain and emotional
hurt. Educating the person with a FASD that substances have helped them deal with
overstimulation and difficulties with self-regulation but there are healthier ways to manage these
problems and get the same result (Cook et al., 2000). Dishion and Kavanaugh (2003) claim
increased parental monitoring can reduce adolescent substance abuse.
Trauma intervention. Bruce Perry (2006) suggests that children with trauma and other
comorbid disorders like FASDs find themselves trapped in negative conflict cycles with their
parents. This leads to power struggles, increased adult frustration, and increased childhood
oppositional behaviour. Caregivers and therapists must discover the triggers that are sending the
children into this affective state and remove or adjust them.
Perry (2006) stresses the importance of physical and psychological safety for children.
Perry is a proponent of patterned, repetitive sensory stimulation to aid the brain in reorganizing,
which could take the form of activities like drumming, running, rocking, jumping, chewing,
lifting weights or chopping wood. Perry (2006) advocates helping children use their body and
FAMILY TREATMENT OF ADHD AND FASD 60
senses to access information about their surroundings as a calming mechanism. If the child can
learn their own triggers and emotional states, then they can learn to seek assistance before their
emotions boil over. Perry (1999; 2002) holds that children can become less anxious with
repeated access to predictable and safe interactions with trusted adults. The focus needs to be on
developing healthy, safe attachments for the child to learn to self-regulate (Barthel & Nickel,
2009).
Justice system interventions. Moore and Green (2004) recommend advocacy support for
persons with FASDs to ensure the consideration of their disability by lawyers, judges, probation
officers, and law enforcement officials. For example, advocacy between the person with a
FASD and their probation officer can focus on developing probation plans that contain
reasonable expectations based on developmental level of functioning, and simple concrete rules
to maximize adherence. Translation of the various legal processes into simple terms should be
required especially for adolescents.
Caregiver support. The task of raising children with FASDs is extremely demanding,
and associated with high levels of stress (Paley et al., 2006). Caregivers often find their needs
for effective support, intervention, and resources remain unmet (Paley et al., 2006). Booth and
Booth (1993) report that “social isolation and lack of support stretch the coping resources of
parents and contribute significantly to their everyday problems of living” (p. 476). Parents
require specialized knowledge about FASDs, assistance in developing effective parenting skills,
and guidance to make effective connections with appropriate resources (Olson, Jirikowic, Kartin,
& Astley, 2007). Liptak and colleagues (2006) report that parent’s desire interaction with other
parents.
FAMILY TREATMENT OF ADHD AND FASD 61
Morrissette (2001) stresses that caregivers must learn stress management and coping
techniques for themselves to best help their child with a FASD. He states, “counselor
intervention and support is critical and increased attention needs to be devoted to prevention and
the systemic implications associated with the stress involved in raising children diagnosed with
FAS” (p. 13). Therapists can mentor parents and build on small successes by mining strengths
(Booth & Booth, 1993).
O’Malley (2007) suggests that parent-to-parent groups for caregivers of children with
FASD are an avenue to gain support and network with like-minded individuals. He explains that
peer support and education can ease the burden of parenting and enhance coping ability. Parents
and caregivers can exchanges ideas about parenting methods and ways to manage the symptoms
of FASDs while acknowledging their children’s strengths. Parent group facilitators can teach
parents self-advocacy skills to help them navigate complicated social services systems.
Additionally many birth mothers will experience intense grief and shame over the fact
that their child has been diagnosed with a FASD, and therapists must ensure that resources are
available to them (O’Malley, 2007).
Special considerations for therapy. FASDs are neurodevelopmental and
neurobehavioural disabilities that make traditional therapy difficult (Malbin, 2008). Many
therapies are ineffective for working with FASDs because they do not recognize underlying
brain dysfunction (Malbin, 2008). Davis and colleagues (2008) agree that therapists have an
ethical duty to design treatment interventions to accommodate impaired social and
communication skills, and the cognitive-behavioural inflexibility of their clients. Gioia and
Isquith (2002) stress that individuals with EF dysfunction do not have the internal resources
FAMILY TREATMENT OF ADHD AND FASD 62
available to initiate desired behaviour in the absence of assistance and reinforcement. Children
will require cues and routines to give meaning to their external environment.
Malbin recommends that all treatment approaches consider the role of the brain
dysfunction in association to a client’s behaviour (Malbin, 2008). Clinicians need to focus on
changing the environment around the person with a FASD, rather than trying to change the
person with a FASD as well as understand that often a person with a FASD cannot do something
even if they want or try to do it. Interventions should target developmental rather than
chronological age. An 18-year-old with a FASD is likely eight years younger developmentally
and therefore still requires structure, guidance, limited choices, and organization by adults
(Malbin, 2008). Ylvisaker and Feeney (1998) explain that “intervention often begins from an
‘external support’ position with active and directive modeling, coaching and guidance by
important everyday people, which proceeds over time to an ‘internal’ process of fading and
cueing” (p. 17).
Integrated case management and multidisciplinary care. The complexities of FASDs
necessitate multidisciplinary involvement (Devries & Walder, 2004; Lockhart, 2001; Premji et
al., 2004). Davis et al. (2008) state that many therapists will take on the role of case managers,
acting as a single point of contact, for organizing community resources, providing education, and
offering general advice. This is especially the case when there a number of comorbid psychiatric
issues that need ongoing monitoring and community support (Huggins et al., 2008; Streissguth et
al., 1996).
Davis et al. (2008) also explain that crises are commonplace in the presence of ongoing
risk and vulnerability factors. Families often need emergency interventions, specialized respite
and extensive transition services. Persons with FASDs and their families often require ongoing
FAMILY TREATMENT OF ADHD AND FASD 63
support and aftercare post-therapy (Morrissette, 2001). For example, post-therapy assistance
may be elicited in regards to vocational support/job coaching, or securing housing or disability
pensions (Morrisette, 2001). Therefore, ideally communities would work together to provide
intensive, specialized, integrated long-term treatment outside of therapy to persons with a FASD
(Carnaby, 2007).
Unfortunately, this broad spectrum of treatment options is not always available,
especially in rural areas. Davis et al. (2008) explain that “in rural settings, the population density
of clinicians and services may be low. Clinicians and other staff are frequently called upon to
perform many roles and struggle to manage in areas outside their core areas of expertise or
competency” (p. 211). Therapists may need to teach other clinicians about the necessary
accommodations needed for a person with FASD.
Intergenerational issues. Parents of children with FASDs often have FASD or PAE
themselves (Malbin, 2008; Mattheis, 2007). Malbin cites a study in which 35% of the mothers
of children with FASDs also had FASDs. Therapists may need to make the same
accommodations for parents and family members as they do for the individual with a FASD. For
example, O’Connor and Paley (2006) mention that one problem with BPT is that many
caregivers struggle with their own effects from PAE and may be less effective advocates for their
children and struggle with new learning. These families need contingency services through
services, resources, education, and training for parents as well as their children.
Association between ADHD and FASDs
There is no firm consensus on the etiology of ADHD due to its heterogeneous cluster of
symptoms (Linnet et al., 2003). In fact, it seems there are many avenues to the manifestation of
ADHD symptomatolagy including genetics, psychopathology, childhood trauma as well as
FAMILY TREATMENT OF ADHD AND FASD 64
prenatal exposure to teratogens. Interestingly, animal studies have shown that in utero exposure
to nicotine, caffeine, ethanol, and stress can also cause neurobehavioural changes similar to those
found in human ADHD (Clarke & Schneider, 1997; DiPietro, Hodgson, Costigan, Hilton, &
Johnson, 1996; Eriksson, Ankarberg, & Fredriksson, 2000; Sobotka, 1989). Ingersoll and
Goldstein (1993) state that “mothers who abuse alcohol or drugs during pregnancy give birth to
babies who suffer from a variety of problems, including ADHD and learning disabilities” (p. 31).
Many researchers in the field of FASDs have found that children with FASDs often carry
a prior or complementary diagnosis of ADHD and have therefore hypothesized a relationship
between the two (Brown et al., 1991; O’Malley & Nanson, 2007). O’Malley and Nanson (2007)
claim there is enough evidence for “a clinical, neuropsychological, and neurochemical link”
between ADHD and FASDs (p. 349). Early studies in this area have found that children exposed
to alcohol throughout pregnancy have deficits in sustaining attention, impulsivity and various
other behavioural problems (Brown, 1991; Streissguth, Sampson, & Barr, 1989). Mattheis
(2007) states that ADHD and LD’s are common cognitive effects of a milder brain injury that
may relate to PAE. In a 2003 study, Burd found that 96.2% of his sample with Fetal Alcohol
Syndrome had ADHD. Burd (2007) also found that ADHD to be the most comorbid mental
health disorder with FASDs.
A study of over 500 children by Mick, Biederman, Faraone, Sayer and Kleinman (2002)
found that ADHD might be a direct symptom of prenatal alcohol exposure outside of prenatal
exposure to nicotine and heritability. In their results, the children with ADHD had been exposed
to daily or binge-style ingestion of alcohol at twice the rate of the non-ADHD controls. In a
more recent exploratory study, Bhatara, Loudenberg, and Ellis (2006) also found evidence of a
possible link between ADHD and prenatal alcohol exposure. A large cohort of over 2000
FAMILY TREATMENT OF ADHD AND FASD 65
children with a FASD were divided into four groups based on differing levels of risk for
gestational exposure to alcohol. Forty-one percent of the children had ADHD, 17% had a
learning disorder, and 16% had ODD and/or conduct disorder. The prevalence of ADHD rates
was consistent with the rate of risk for alcohol exposure in the groups, signalling a possible
association between the two disorders by this research team.
Fryer et al. (2007) believe that PAE should be considered a possible factor in the
pathogenesis of childhood psychiatric disorders, as PAE is often associated with ADHD and
FASD, which are in turn associated with increased risk for mental illness (Coles, Platzman,
Lynch, & Freicles, 2002; Mattson, Calarco, & Lang, 2006; Steinhausen, Willms, & Spohr, 1993;
Steinhausen & Spohr, 1998).
Despite the cited body of literature, which supports a link between ADHD and PAE, other
studies have not found a singular association apart from other variables like nicotine, parental
psychopathology, and current parental substance use (D’Onofrio et al., 2007). O’Malley and
Nanson (2007) suggest that the clinical quality of ADHD in children with a FASD is different
from those with ADHD without FASD. Children with a FASD and comorbid ADHD tend to
have earlier onset ADHD of a primarily inattentive, rather than hyperactive subtype, and often
have many concurring developmental, psychiatric and medical conditions (D’Onofrio et al.,
2007; O’Malley & Nanson, 2009; Roebuck et al., 1999). Two other comparable studies found
that the neurocognitive deficits of FASD and ADHD are not equal, and that the two disorders
create different patterns of deficits (Coles, 2001; Coles et al., 1997).
Literature Review Summary
To summarize, both ADHD and FASDs are complex disorders that alter brain
functioning in affected individuals. There is a plethora of clinical research evidence on treating
FAMILY TREATMENT OF ADHD AND FASD 66
ADHD but less on treating FASDs. However, many of the treatment approaches put forth for
treating these ADHD and FASDs are identical, complementary or can overlap. The benefits of
psychosocial interventions for both ADHD and FASDs can be found in the literature (Branman
et al., 2009; Brown, 2000).
The literature indicates that the most appropriate therapeutic interventions recognize and
accommodate neurological impairments in clients (Davis et al., 2008; Malbin, 2008). The
therapist’s attitude should be dynamic, direct, brief, encouraging, and affirming (Harwood &
Eyberg, 2004; Nadeau, 2005). Complex cases, such as Todd and Nancy’s file, benefit from a
strengths-based, family-centred, and multidisciplinary framework (Devries & Walder, 2004;
Lockhart, 2001; Premji et al, 2004). Within that framework specific multimodal techniques and
interventions such as modified CBT, psychoeducation, life and social skills training, self-
regulation training, self-esteem and strengths building, psychodynamic group experiences,
substance misuse counselling, adapted behaviour parent training, environmental
accommodations and parent-teen mediation (Acro et al., 2004; Bagwell et al., 2001; Barkley et
al., 2001; Bertrand, 2009; Booth & Booth, 1993; Brown, 2000; Chromis et al., 2004; Davis et al.,
2008; Edwards, 2002; Malbin, 2008; Wilens, 2004). It is also advisable that clients receive a
multidisciplinary assessment for treatment to be beneficial and specific (Lockhart, 2001; Premji
et al., 2004).
Case Formulation
Diagnostic Impressions
It was clear from the initial intake and assessment session that Todd and Nancy were in
need of intervention, support and education. The family had little material and and interpersonal
resources and were at high-risk for further escalation of their concerns and Todd’s challenging
FAMILY TREATMENT OF ADHD AND FASD 67
behaviours. If left untreated, the family’s functioning would likely continue to worsen over time
(Cantwell, 1996; Schubiner, 2005).
Review of presenting issues. Nancy had struggled with alcohol abuse in the past, and
typically used alcohol as a coping mechanism. Nancy admitted to using alcohol during her
pregnancy with Todd, most significantly in the first three months before she knew she was
pregnant. Todd had difficulty attaching securely to Nancy from birth, and faced a number of
developmental delays in infancy and childhood. Nancy and Todd had both been involved in
family violence episodes for which they received prior counselling. Todd had regrettably been
the victim of childhood physical and verbal abuse.
Todd’s behaviour became increasingly negative during and after puberty. He grappled
with self-regulation and anger problems, anxious and depressive thoughts, and self-esteem. At
times Todd has become physically and verbally abusive toward his mother and others when
faced with unplanned changes in his routine or excessive cognitive demand. Todd used
marijuana and alcohol to cope with daily stressors and other chronic problems. He was forgetful,
impulsive, immature for his chronological age, and slow at processing incoming stimuli of all
forms. Todd has also been in trouble with the law and incurred schools suspension for truancy
on multiple occasions. The quality of Nancy and Todd’s relationship was poor, and Nancy often
defaulted to yelling and increasing demands when Todd was uncooperative, rendering Todd
more overwhelmed.
Past diagnoses. In the second grade, a school psychologist diagnosed Todd with ADHD.
She recommended Todd undergo a neurodevelopmental exam. Todd’s major psychiatric
assessment at age 14 linked Todd’s substance use, challenging behaviour, and sporadic anger
FAMILY TREATMENT OF ADHD AND FASD 68
outbursts to his ADHD, past trauma, poor parent-child attachment and various environmental
triggers.
Todd’s inattentiveness and hyperactivity/impulsivity were apparent from our first session
together and were typical of his functioning since childhood. In our first session, Todd was
constantly fidgeting with his hands, and popping in and out of his seat. He was often distracted
in conversation, and had difficulty following instructions or paying attention to detail in any kind
of task, whether at home or at school. Nancy said that he would frequently lose items and was
always forgetful. Todd needed to move around to attend to any length of conversation or
allowed to engage in something tactile, like drawing or playing with a fidget toy. Todd’s
hyperactivity/impulsivity manifested itself through risk-taking behaviour and his poorly thought
out decisions. All these behaviours were consistent with the diagnostic criteria for ADHD in the
DSM-IV-TR (APA, 2000).
Prior assessment recommendations. Todd and Nancy had come to therapy with a
large amount of background information. It was necessary to review the recommendations that
previous professionals had made for Todd and Nancy in the past, and to see what had been
successful, and what had failed, or not yet been attempted.
Todd had undergone two separate psychoeducational assessments in Grades 2 and 7, and
a psychiatric evaluation at age 14. Todd’s reports all had recommendations for individual
therapy, life and social skills training, and BPT for his mother. Suggestions for Todd’s family to
learn his triggers and modify his environment to minimize their occurrence were also present.
School reports indicated that Todd worked best in destimulated environments that allowed him
to engage in short learning sessions and have frequent breaks. Teachers were asked to use fewer
FAMILY TREATMENT OF ADHD AND FASD 69
words during instruction, implement visual aids in the classroom, and offer Todd reminders and
directives.
Todd did attend two programs between the ages of 14 to 15 that taught life and social
skills, alongside substance misuse counselling, and self-esteem building. The counsellors at both
programs noted that although Todd could verbalize new learning, he had trouble with retention
and generalization outside of sessions. It was recommended that Todd continue accessing some
form of structured residential program, or mimic the design in his home community though
community support, parental structure, consistency and supervision and through advocacy
assistance.
Anticipated diagnosis. In Todd’s major psychiatric report at age 14, his psychiatrist
questioned whether his profile was consistent with PAE and/or a FASD. Todd’s impaired
functioning across multiple domains seemed to be beyond the traditional scope of ADHD. The
DSM-IV-TR (APA, 2000) criteria states that a diagnosis of ADHD should occur exclusively of a
pervasive developmental disorder or any other mental disorder (APA, 2000, Section E). FASDs
are not pervasive developmental disorders, but they are pervasive neurobehavioural disorders
(Malbin, 2008). Research demonstrates that individuals with a FASD can also have ADHD, or
that ADHD is sometimes a symptom of PAE (Brown et al., 1991; Burd, 2007; Mattheis, 2007;
O’Malley & Nanson, 2007).
Todd demonstrated many of the primary and secondary symptoms associated with
FASDs (Bookstein et al., 1998; Coggins et al., 2003; Kelly et al., 2000; Malbin, 2008; Novick &
Streisssguth, 1995; Semrud-Clikeman & Ellison, 2009; Streissguth et al., 1998; Streissguth,
2001). In terms of primary symptoms, Todd had slow processing speed, memory deficits,
impaired verbal comprehension, impulsivity, sensory defensiveness, EF malfunctions, lack of
FAMILY TREATMENT OF ADHD AND FASD 70
empathy, perseverative behaviours, developmental dysmaturity, trouble connecting his actions to
consequences as well as difficulty generalizing learning from one scenario to another (Malbin,
2008). He also fit the behavioural profile of individuals with a FASD laid out by Bookstein and
colleagues (1998) which includes emotional lability, deficient social interactions, and personal
manner impairments. Todd was also prone to depressive thoughts and anxiety, two common
manifestations of psychopathology in those with FASDs (O’Connor & Kasari, 2000; O’Connor
& Paley, 2006; Lemola et al., 2009; Olson et al., 2001; Streissguth, 2001).
I hypothesized that if Todd had a FASD and had never received treatment, that he had
developed a host of secondary symptoms in response to chronic frustration and failure (Malbin,
2008). His challenging behaviours and mental health issues had escalated with age as Todd
encountered increased demands to be responsible and mature. Todd displayed many behavioural
symptoms associated with untreated FASDs including trouble with the law, school disruption,
mental health problems, substance misuse, challenging behaviours, emotional reactivity, low
self-esteem, and issues with maintaining employment (Clark et al., 2004; Malbin, 2008;
Streissguth et al., 1996). Adults had assumed that Todd’s poor behaviour was intentional
because there were many things he could do well that masked his underlying brain dysfunction
and mental health problems (Clarke et al., 2004; Malbin, 2008; Mattheis, 2007).
Todd had also experienced childhood abuse in addition to witnessing family violence. I
believed his early childhood experiences had further compounded his brain dysfunction. As
Putnam (2006) explains, trauma alters the ability to self-regulate and manage one’s own
behaviour and hinders brain development (Perry 1999; 2002). This could explain why Todd’s
adaptive functioning was so low, and his symptoms were so severe (Henry et al., 2007).
FAMILY TREATMENT OF ADHD AND FASD 71
Children with PAE and trauma manifest the most severe range of brain dysfunction (Barthel &
Nickel, 2009; Henry et al., 2007).
Upon intake to therapy, Todd’s potential FASD was yet untested and unconfirmed.
Researchers assert that proper diagnosis of a FASD is crucial for accessing resources,
minimizing mental health problems, and for reducing frustration among children and their
caregivers (Chudley et al., 2005; Hoyme et al., 2005; Mills et al., 2006; Novick & Streissguth,
1995). With the confirmation of alcohol exposure in pregnancy from Nancy it was my opinion
that a FASD could be the etiology of Todd’s extreme challenging behaviour, his mental health
issues, and a key contributor to his ADHD symptomatolagy and EF deficits. On all three of the
screening measures that I implemented with Todd and Nancy, Todd scored in the range that
warranted closer evaluation by a medical doctor, therefore a referral to a paediatrician had been
of paramount importance. A paediatric referral was the first-step in accessing a professional
multidisciplinary assessment for a FASD for Todd.
Multiaxial assessment and global assessment of functioning. Figure 1 displays Todd’s
multiaxial assessment based on initial case information. Todd’s Global Assessment of
Functioning (GAF) score was placed at 50 since he was exhibiting serious symptoms (e.g.,
truancy, shop lifting, anger, substance misuse) and appeared to have serious impairments in
social, occupational and school functioning (e.g., no real friends, unable to keep a job or attend
school; APA, 2000).
Figure 1: Multiaxial Assessment
Axis I: Clinical Disorders
Diagnostic Code DSM-IV Name
314.01 Attention-Deficit/hyperactivity disorder, Combined type
V61.20 Parent-child relational problems
FAMILY TREATMENT OF ADHD AND FASD 72
Axis II: Personality Disorders and Mental
Retardation
None
Axis III: General Medical conditions
None
Axis IV: Psychosocial and Environmental
Problems
Category Specifications
Problems with primary support group Attachment/relational issues with parent
Problems related to social environment Easily manipulated/hard time making real friends
Educational problems Truancy, suspensions, poor grades
Occupational problems Terminated from employment frequently
Housing problems Family moves frequently for not paying rent
Economic problems Mother works part-time and receives no spousal support
Access to health care services Confusing to family, need assistance
Interaction with legal system/crime Offences made, court hearing, probation
Other psychosocial and environmental
problems
Alcohol and Cannabis misuse
Axis IV: Global Assessment of
Functioning
Score: 50 Date: October 2009 (initial client contact)
Treatment Plan
Nancy and Todd faced multiple concurrent challenges both past and present, and finding
a therapeutic point of entry was somewhat daunting. Although research for the success of early
intervention is prevalent in the literature for ADHD and FASDs, Todd had never had the
opportunity to access ongoing treatment aside from his two weeks at a psychiatric hospital
(Guralnick, 1997; Morrissette, 2001; Streissguth, 2001; Streissguth et al., 1996). The family had
been reluctant to pursue therapy for any length of time in the past according to reports; therefore,
I felt it would be imperative to build trust with them for both practical and retention purposes
(Chromis et al., 2004; Harwood & Eyberg, 2004; Ramsay & Rostain, 2005). From that
FAMILY TREATMENT OF ADHD AND FASD 73
foundation, I could work towards stabilizing the family’s level of functioning and towards
enhancing their diminished coping ability (Davis et al., 2008).
Main therapeutic approach. This family’s issues were multi-faceted, complex, and
stretched across multiple domains. Bernstein (1996) recommends that therapy for those with
cognitive difficulties focus on relationship and self-esteem building, rather than client insight and
rapid change. Therefore, I decided that a multi-modal approach to therapy, operating from a
family-centred strengths-based framework was the best choice for treatment. Multi-modal
approaches are highly effective for families facing multiple barriers (Bertrand, 2009; Cantwell,
1996; Edwards, 2002; EPC, 2008; Goldstein, 1996; Green & Albon, 2001; Harris, 2000;
Henggeler & Lee, 2003; Henggeler et al., 2003; Klassen et al., 2004; Miranda et al., 2006;
Pelham & Gnagy, 1999; Ratey et al., 1992; Rostain & Ramsay, 2006; Stoddart, 1999). For
example, O’Malley (2007) believes a multi-modal, or technically eclectic approach to therapy is
necessary for assisting families affected by FASDs.
According to Vargas and Prelock (2004) family-centred approaches do maximize
treatment value. Family-centred strengths-based approaches correlate to higher levels of client
reported satisfaction and empowerment in therapy as well as increases in self-esteem and coping
ability (Dempsey & Dunst, 2004; Healthy Child Manitoba, 2007; King et al., 1999).
Specifically, the CHM focuses on the development of the therapeutic relationship, which is
integral to supporting those affected by FASDs (Dempsey & Keen, 2008; Madsen, 2009; Malbin,
2008; Ory & Dykstra, 2007; Selekman, 2010). My intention was to help Todd and Nancy move
towards a better future at their own pace, and according to their needs and goals (Dunst et al.,
2002; Madesn, 2009; Selekman, 2010).
FAMILY TREATMENT OF ADHD AND FASD 74
Therapeutic adaptations. Adaptations to traditional therapy were necessary to
accommodate Todd’s impaired cognitive abilities. Experts recommend that therapist be
directive, interactive and solution-focused (Hallowell, 1995; Hallowell & Ratey, 1994). I did
expect that there might be missed appointments, lack of follow-through, and some degree of
challenging behaviour throughout the course of therapy due to the family’s issues (Ramsay &
Rostain, 2005). I let Nancy and Todd know that I would give them reminder calls before
appointments and write any instructions or homework down on paper.
Expected duration of services. I anticipated that my interventions with Todd and Nancy
would be long-term and ongoing as is with most clients where brain dysfunction is present
(Davis et al., 2008). Moore and Green (2004) stress that early removal of supports should be
avoided as it can be extremely detrimental to families.
Interventions for Todd. Todd was my identified client, but my work with him needed
to take place in both a family and community context to be effective and long lasting. Having
Nancy involved in Todd’s care would allow her to help him practice new skills outside of
therapy (Pelham & Gnagy, 1999). Todd’s daily environment and the expectations of those
around him had proven to be more than he could handle. Kendall et al. (1990) affirm that under-
achievement and over-expectation can lead to poor self-esteem in those with neurobehavioural
conditions. I felt he could benefit immediately from lowered frustration levels and from
interventions aimed at increasing his self-esteem. In the past, Todd had performed best in
structured one-to-one learning scenarios so I believed that the therapeutic process could aid him
in a number of ways.
On the topic of pharmacotherapy, I explained to the family that there is strong support for
medication to treat ADHD, and some evidence for medication to treat the comorbidities of
FAMILY TREATMENT OF ADHD AND FASD 75
FASDs (Abikoff, 1991; Fabiano & Pelhmam, 2003; Famy et al., 1998; MTA Cooperative Group,
1999; O’Connor et al., 2002; Okie, 2006; van der Oord et al., 2007). Ideally, Todd would have
received a combined treatment of therapy with medication, as it is considered the most effective
approach for those with comorbidities and complex subtypes (EPC, 2008; Pelham & Gnagy,
1999). However, neither Nancy nor Todd wanted Todd to be on medication for ADHD, and his
psychiatrist had advised against it at Nancy’s insistence that Todd would sell the medication for
profit.
I anticipated that therapy would help Todd to develop his personal strengths (i.e.,
mechanical inclination, athleticism, kinaesthetic aptitude, determination, affability, and
creativity). However, for therapy to be helpful for Todd, I knew I would have to accommodate
Todd’s impairments in receptive language, and limit sole reliance on oral methods when working
with him in therapy (Novick & Streissguth, 1995; Portie-Bethke et al., 2009). It was essential to
consider Todd’s underlying brain dysfunction in all my treatment planning (Davis et al., 2008). I
intended to use simple visual and psychodynamic methods to teach any new concepts including
rehearsal and hands-on learning (Hanna et al., 1999). I also would use repetition, consistency,
and direction to aid Todd in maintaining focus and attention. I planned to keep therapy sessions
with Todd short, low-intensity and to schedule them on consistent times and dates (Bernstein,
1996; Estenson, 2003; Selekman, 2010).
At the time of intake, Todd was not in school and was spending all day at home with
nothing to engage him and no structure to his day. This lack of structure and parental monitoring
was detrimental to Todd’s progress, so another goal was to find him a structured activity to do in
the day. I planned to research alternative programs both local and outside of town.
FAMILY TREATMENT OF ADHD AND FASD 76
Overall, I decided to implement a multi-modal therapy approach (see Table 1), tailored to
Todd’s needs, that was family-centred and strengths-based in its delivery (Vargas & Prelock,
2004). I developed Todd’s treatment plan from evidence-based literature for psychosocial
interventions for ADHD and FASDs. Treatment for all these conditions can mitigate
interpersonal and behavioural issues (Acro et al., 2004; Cantwell, 1996; Robbins, 2005; Okie
2006; Thomas et al., 2008). Many of the suggested treatments for these conditions overlap and
complement one another, as they are all conditions based in the brain that affect functioning and
behaviour.
Table 1: Todd’s Therapy Treatment Plan
Intervention Details Literature Support
Modified CBT/ Psychoeducation
Life and social skills training
Self-regulation training
Psychoducation on ADHD and FASD and
their affect on behaviour, CBT to increase
self-concept, target negative and anxiety-
based cognitions, reframe thoughts,
enhance awareness of feelings, teach
problem solving and self-instruction
Learn new skills to cope with daily
stressors; topics to include anger
management, positive communication,
assertiveness, reading social cues;
vocational assistance, social skills, body
language, time management, relationship
building, use worksheets, stories, scripts;
focus on repetition, consistency, and
teaching specific rules and expectations; use role-play, rehearsal, and kinaesthetic
modalities.
To reduce negative socio-emotional
outcomes and to increase self-control for
better quality of life; to aid with
consequences of childhood trauma; include
relaxation training, progressive muscle
relaxation, visualizations, imagery work;
patterned and repetitive sensory stimulation
Acro et al., 2004; Barkley et al., 2001;
Branham et al., 2009; Brown, 2000;
Calderon, 2001; Hurley, 2005; Lochman et
al., 2003; Miranda & Presentacion, 2000;
Miranda et al., 2006; Murphy, 2005; Olson
et al., 2001; Ramsay & Rostain, 2005; Wiggins et al., 1999
Acro et al., 2004; Bagwell et al., 2001;
Barkely et al., 2000; Branham et al., 2009;
Dishion & Kavanaugh, 2003; DuPaul &
Stoner, 1994; Evans et al., 2004; Henggeller
et al., 1998; Hesslinger et al., 2002;
Murphy, 2005; Novick & Streissguth, 1995;
Ramsay & Rostain, 2005; Robbins, 2005;
Selekman, 2010; Streissguth & O’Malley,
2000; Walthall et al., 2008; Wiggins et al., 1999
Acro et al., 2004; Benson & Havercamp,
2007; Bertrand, 2009; Douglas, 2005; Foxx,
2003; Malbin, 2008; Moore & Green, 2004;
Morrissette, 2001; Novick & Streissguth,
1995; Perry, 2006; Selekman, 2010:
Streissguth & O’Malley, 2000; Walthall et
al., 2008
FAMILY TREATMENT OF ADHD AND FASD 77
Self-esteem and strengths
building/self-advocacy training
To enhance interpersonal relationships,
self-worth and the capacity to self-advocate
Brown, 2000; Edwards, 2002; Glass &
Myers, 2001; Hanna et al., 1999; Lennox et
al., 2004; Nadeau, 2005; Okie, 2006; Portie-
Bethke et al., 2009; Selekman, 2010;
Sonuga-Barke et al., 2001
Psychodynamic Group
Experience
Research if Todd can attend another type of
residential course in the future if he is
unable to return to school
Davis et al., 2008; Weinberg et al., 2008
Address substance misuse For health and well-being; educate on the
use of substances for self-soothing, the affect of substances on the body; attempt to
replace misuse with pro-social and
productive behaviours; teach stress relief
skills; emphasize strengths
Alati et al., 2008; Boer et al., 2003; Cook et
al., 2000; Malbin, 2008; Rathburn, 1996, Wilens, 2004
Access a multidisciplinary
assessment for a FASD
To give service providers a proper
blueprint for intervention and support
Astley & Clarren, 2000; Chudley et al.,
2005; Di Nuovo & Buono, 2007; Hoyme et
al., 2005; Streissguth, 2001
Interventions for Nancy. Nancy self-reported as isolated and overwhelmed and this was
negatively affecting her relationship with her son. She had limited access to resources and
struggled with her own personal challenges, as many parents of children with FASDs seem to do
(Booth & Booth, 1993; Paley et al., 2006). Nancy was an integral part of Todd’s treatment plan
as the most permanent force in his life (Dempsey & Keen, 2008). If Nancy’s functioning could
stabilize, she would be in the prime position to offer information, support, and advocacy for
Todd on an ongoing basis (Dunst et al., 2002; Estenson, 2003). Nancy’s frame of mind and her
moods affected Todd’s emotional well-being and coping abilities. This interconnectedness
solidified my plan to work from a family-centered strengths-based approach, with multi-modal
interventions (Vargas & Prelock, 2004).
However, I was also keenly aware that Nancy had her own cognitive limitations, and that
she would need many of the same accommodations for new learning that Todd did (Hurley,
2005; O’Connor & Paley, 2006). My goal was to work in small steps, and celebrate all
FAMILY TREATMENT OF ADHD AND FASD 78
successes. I knew it would be important not to get ahead of Nancy’s desired pace if I wanted her
to stay in therapy. Table 2 shows Nancy’s treatment plan.
Table 2: Nancy’s Treatment Plan
Intervention
Details and Aims Literature Support
Adapted Individual support Increased parent well-being is linked to a
reduction in child symptoms. Assistance
for venting, advocacy, encouragement, and
stress reduction; mine strengths; offer
mentorship; work with feelings of guilt
and shame
Chromis et al., 2004; NCDSS, 2004;
O’Malley, 2007; Sonuga-Barke et al., 2001
Group peer support Parent-to-Parent group attendance each week to enhance coping, promote bonding,
ease parenting burden and reduce
frustration; parent relief from the foster
parent association; increased connections
with community agencies
Booth & Booth, 1993; Liptak et al., 2006; O’Malley, 2007l; Morrisette, 2001; Olson
et al., 2007
Joint interventions. Sonuga-Barke et al. (2001) state that poor interpersonal
relationships with caregivers can trigger challenging behaviours in children. Selekman (2010)
directly links poor attachment between children and their caregivers with self-destructive
behaviour in children. Children need to develop healthy and safe attachment to self-regulate
their emotions and behaviour (Barthel & Nickel, 2009). Concurrently, the quality of the
therapeutic relationship can influence the ability to parent effectively (Tymchuk, 1990).
Encouragement, support and re-education would be of paramount importance.
Nancy needed to obtain a better understanding of why Todd acted the way he did, and
understand that his behaviour derived from his impaired brain functioning, and a lack of external
recognition of his true capacity and abilities (Levine, 1995; Malbin, 2008). Malbin (2008) states
that recognizing strengths in a child with a FASD and being able to identify what behaviours are
actually symptoms of neurological dysfunction can improve outcomes.
Perry (2006) asserts that children with trauma histories and comorbid conditions can
become trapped in negative conflict cycles with their parents, and therefore parents must learn to
FAMILY TREATMENT OF ADHD AND FASD 79
removed or adjust inflammatory triggers in the child’s environment to reduce conflict. As a
dyad, my aim was to ameliorate the cycle of conflict between Todd and Nancy through BPT, the
CHM interventions and psychoeducation. I proposed to do this through enhanced understanding
of Todd’s brain dysfunction, positive parenting and communication, and parent-teen mediation
(Barkley et al., 2001; Perry, 2006). Prevention via identification of triggers and new skills
building would allow Nancy and Todd to reduce frustration and resistance to one another (Henry
et al., 2007). Table 3 shows the joint treatment plan for Nancy and Todd.
Table 3: Joint Interventions for Todd and Nancy
Intervention
Details and Aims Literature Support
Adapted Behaviour Parent
Training and Collaborative
Helping Model interventions to
increase healthy attachment
Role-model positive behaviours
Behaviour management to reduce
challenging behaviour; detecting etiology
of behaviours (i.e., triggers) and
brainstorming ways to remediate;
modeling and teaching positive parenting practices and appropriate consequences;
increasing parental monitoring; stopping
intermittent parenting; increasing
structure; spending more time with Todd;
communication and listening exercises;
parent-teen mediation;
Stop substance misuse in front of Todd
Acro et al., 2004; Barkley et al., 2001;
Bernstein, 1996; Bertrand, 2009; Brown,
2000; Chronis et al., 2004; Dishion &
Kavanaugh, 2003; Dopfner et al., 2004;
Emerson, 2000; Eyberg et al., 2008; Fabiano & Pelham, 2003; Ingersoll &
Goldstein, 1993; Kazdin, 1997; Madesen,
2009; Moore & Green, 2004; Morrissette,
2001; Pelham et al., 2005; Olson et al.,
2001; Selekman, 2010; Shanley & Niec,
2010; Streissguth et al., 2004; Streissguth
& O’Malley, 2000
Schubiner, 2005
Psychoeducation on Todd’s
diagnoses and their impact on
behaviour and functioning
Environmental Accommodations
Developing realistic expectations for Todd
and for therapy; understanding the link
between brain dysfunction and behaviour; taking Todd’s developmental dysmaturity
into consideration; making allowances for
Todd’s slow processing speed by giving
extra time; become an advocate for Todd;
learning coping tools; increasing Todd’s
resiliency
Create a “good fit” for Todd; modify home
environment for Todd to reduce stress and
anxiety; de-clutter, reduce noise; reduce
demands; implement visuals
Acro et al., 2004; Bertrand, 2009; Green,
2007; Levine, 1995; Nadeau, 2005;
Lennox et al., 2004; Malbin, 2008; O’Malley, 2007; Ramsay & Rostain, 2005;
Selekman, 2010; Vig & Kaminer, 2002
Edwards, 2002; Healthy Child Manitoba,
2007; Ingersoll & Goldstein, 1993;
Malbin, 2008; Riley et al., 2004; Robbins,
2005; Schubiner, 2005
FAMILY TREATMENT OF ADHD AND FASD 80
Work with other professionals. A multidisciplinary treatment approach is
recommended in the literature when working with brain dysfunction (Devries & Walder, 2004;
Lockhart 2001; Premji et al., 2004). However, helping Nancy and Todd access all the resources
they required was difficult in a rural area that lacked many amenities and access to certain
professionals. Ideally, Todd would have had access to a paediatrician, psychiatrist and
psychologist on a regular basis, but there was no one in town with those credentials.
Under Canadian best-practices guidelines, it was necessary for Todd to receive a
multidisciplinary assessment for a FASD (Chudley et al., 2005). However, this required a visit
to a paediatrician in a city two hours from the town where Todd lived, and then a further referral
to a regional government-funded assessment clinic four hours away. The waitlist for a
multidisciplinary assessment for a FASD was around three months. Davis and colleagues (2008)
contend that service providers may end up filling multiple roles in an attempt to assist families
reach their best possible outcome.
Despite the evident rural limitations, there were resources in town that I could connect
with Todd and Nancy. One was a provincial organization that assists persons with developmental
delays. Todd and Nancy had been referred once before when they lived in a bigger centre but did
not follow-up. It was possible for Nancy and Todd to apply for funding to provide them with a
vocational support worker as well as parent respite opportunities.
Todd also had a probation officer that Nancy wanted me to work with regarding Todd’s
understanding of his probation rules. Moore and Green (2004) recommend that probation
officers be in frequent contact with young offenders affected by mental health issues, and
provide intense supervision, immediate incentives and follow-through, as well as concrete and
simple rules. Unfortunately, Todd’s probation officer only saw him once a month as he worked
FAMILY TREATMENT OF ADHD AND FASD 81
over an hour away and therefore, Todd lacked any formal supervision from the justice system.
The probation officer often promised incentives that he never delivered on and took an
authoritative and verbal approach that did not work well for Todd. It seemed that I needed to
work in conjunction with Todd’s probation officer to help Todd adhere to his probation rules and
expectations as Todd’s impairments put him at a constant disadvantage. I also let the family
know that I could assist them in navigating the justice system as an advocate to ensure
consideration of Todd’s disability by legal officials (Moore & Green, 2004).
Self-care. Early research alerted me to the fact that working with a family affected by
ADHD, FASD and other comorbidities would be extremely challenging (Rathburn, 1996). I
knew I would depend on my supervisor and colleagues to debrief and re-focus when therapy
would inevitably become overwhelming. It was obvious to me that the journey with the family
might be as full of successes as failures and I would need to operate from a stance of empathic
detachment if possible (Pringle-Nelson & Perry, 2006).
Treatment Summary
Month One
In the first month of working with Todd and Nancy, I organized to see Todd and Nancy
together once a week, and Nancy alone once a week. Since the family had been in a state of
crisis my primary overarching goal was to stabilize family functioning to a manageable level.
My plan was to start individualized sessions with Todd after the first month of joint sessions with
him and his mother. I believed Todd would be more receptive to individual counselling once we
worked on some important issues between him and his mother, and after his mother learned
some new skills to implement at home that would lessen the stress of his environment. I also felt
if I could build trust with Todd while his mother was ensuring he came to sessions, the transition
FAMILY TREATMENT OF ADHD AND FASD 82
to one-on-one sessions would be easier. After Nancy learned some new skills and received peer
support, I could focus my clinical interventions on Todd.
Nancy’s sessions. Nancy’s sessions were developed from principles of
psychoeducation, BPT and the CHM. My aim was to teach her new parenting skills, self-care
skills, find her support networks, and help her recognize her own skills, strengths, and positive
abilities.
Session one: My first session with Nancy was an opportunity to build rapport, and to
offer her support and hope for her and her son’s situation. Nancy became tearful when she
recounted the frustrations and hardships she had endured as a single parent. She said she felt like
a failure as a parent, and felt guilt about all the things that Todd has also gone through as a child
and teenager. I empathized with her situation and story while emphasizing things that she had
done well as a parent, like seeking assistance, and never giving up on her relationship with her
son. I focused on her resiliency and survival rather than on her perceived failures and mistakes.
I introduced the idea to Nancy that her increased well-being could lessen the severity of
Todd’s symptoms. I explained to Nancy that with enough support she would find that her
circumstances could become more manageable. Nancy agreed to register for the parent-to-parent
group at the agency, where parents shared tips and ideas for raising their children with
behavioural and developmental challenges. There was also a weekly lesson on a topic related to
parenting children with special needs that I felt would benefit her and Todd. At the end of the
session, Nancy reported that she felt more empowered and ready to work towards small
successes with Todd. She also said she was looking forward to meeting other parents who were
also struggling with raising their children.
FAMILY TREATMENT OF ADHD AND FASD 83
Session two: In our second session, Nancy and I started a dialogue on how brain
dysfunction affects behaviour. With a white board, and other visual handouts, I started to teach
Nancy the concept that Todd was developmentally younger that he appeared, and therefore her
demands, expectations and consequences for Todd should be targeted to a child much younger
that sixteen. Nancy found this idea confusing, so we did some role-plays where I acted like a
child at the age of eight and she reacted to my behaviour. I coached her on alternatives and other
possible responses. Nancy found this manner of teaching helpful. Nancy also reported that she
enjoyed the parent group, and that she has learned a lot from the other parents. She said it was
nice to take a break to spend time with other adults who understood what she was going through.
Session three: In our third session, Nancy and I talked about understanding Todd’s
triggers. I asked Nancy to recount two scenarios where Todd had become angry and destructive.
Then I taught her the concept of “being a detective” and working backwards from the incident to
see what might have triggered Todd’s response before the event in question. We spoke about all
the types of sensory overload and ways she could reduce demands in the home.
It seemed that Todd often became destructive when left alone for a long period without
contact from Nancy. Nancy had the realization that if she left an eight-year-old at home alone
without letting them know when she would be coming back the child would probably also have a
panic attack or fit or rage from anxiety and fear. I explained to her that Todd’s emotional
response was developmentally rather than chronologically appropriate. Nancy decided not to
leave Todd home alone without adult supervision.
Nancy and I also spoke about ways she could destiumlate the environment at home. I
asked Nancy what small step she felt she could attempt in regards to decluttering the house.
Nancy suggested working on the kitchen fridge door first, as it was full of photos, magnets, and
FAMILY TREATMENT OF ADHD AND FASD 84
papers. She also liked the idea of a home wall calendar where she could list her work shifts and
appointments for Todd and herself to see.
Session four: Nancy did not arrive on time for her fourth session. When I called her at
home, she said she had forgotten but would come in right away. By the time she arrived, we
only had half-an-hour left so I decided we would watch a short video for parents on ADHD. I
thought the visual nature of learning would appeal to her. I reminded Nancy to write down our
session times on the home calendar. Nancy also filled out her first session rating form for our
first month of work. She placed herself at 8/10 for relationship, goals and topics, approach or
method, and a 9/10 overall. She said she was feeling pleased with how things were progressing
thus far.
Joint sessions. Nancy and Todd also needed a safe space to work on their attachment,
and to mediate the conflicts between them. With Nancy receiving education in our individual
session, I felt she would be more amenable to looking at things from Todd’s perspective in joint
sessions. My plan was to model positive communication to the family, using my own behaviour
as a guide for their own interactions at home.
Session one: In our first joint session, I suggested to Todd and Nancy that we could
work on two things: (a) the quality of their relationships; and (b) mediating ways to reduce
conflict at home. Todd and Nancy both expressed a desire to work on these goals at intake.
However, I noted that before we started working on these goals, we would have to work on some
rudimentary communication skills. I wanted the pair to have a few simple tools for talking with
one another effectively so we went over “I” statements (i.e., I feel [insert feeling] when you
[insert action] because I [insert reason] so can you [insert new preference] from now on), not
interrupting others while they are speaking, and the basics of reflective listening. We did a few
FAMILY TREATMENT OF ADHD AND FASD 85
exercises to practice. I told them these communication rules would be on the white board
whenever we did joint sessions to remind them.
Session two: I reminded Nancy and Todd of the communication ground rules we had on
the whiteboard at the office. I asked Todd and Nancy to each list one concern that they had with
the other’s behaviour, so that we could brainstorm solutions. Once they agreed on some new
solutions, they could post their agreement on the wall at home to remind them of their goals.
Todd asked to go first and Nancy agreed. Todd said he felt that Nancy yelled too much and it
stressed his nerves. Nancy stated that she got angry because Todd never listened to her or
followed through on her requests. When she got angry, Todd would call her names, which
further escalated their conflict. Then Todd would often leave the house without telling Nancy
where he was going.
I asked Todd how he learned new things best, and he responded that he learned best when
someone showed him rather than told him. He also said he liked when people tell him one thing
at a time. I asked Nancy if she could try showing Todd what she wanted him to do rather than
tell him, and if she could try coaching him through requests step-by-step. Nancy was agreeable
to this but felt that Todd also needed to respect her. I asked Todd to tell Nancy if he needed a
“brain break” if he became too overwhelmed, and go for a ten minute walk around the
neighbourhood and come back home. Todd was willing to try this idea as well. The new plan
details were written out for the family to take home and work on for the coming week as
homework.
Session three: I checked in with Nancy and Todd about the agreement from last week.
Nancy said she had forgotten to put the terms up at home but they had tried some of the ideas.
Todd said his mom was yelling less the past week but she was still using too many words when
FAMILY TREATMENT OF ADHD AND FASD 86
making requests. Nancy emphasized that she was trying, and I reiterated to Todd that it would
take time and effort on both their parts for things to change.
Nancy was concerned that Todd was using the “brain break” to leave the house to avoid
chores and that he would leave for longer than the agreed upon time. I suggested that Todd use a
digital watch, and let Nancy program if before he left. If he did not return by the alarm, he
would have to face a consequence. Todd suggested chopping wood because he also found it
relaxing. The agreement was revised to address these issues and I reminded Nancy to put the
agreement up at home, as it would help remind her and Todd of what they were supposed to be
trying to do.
In an effort to build better attachment between Todd and Nancy, I put forth the idea of a
scheduled weekly family activity that they would both find enjoyable. Nancy said that both her
and Todd liked movies. Todd said he would be willing to do a family movie night once a week
on Sunday. Nancy said she could also cook Todd’s favourite dinner that night. I felt that this
would be a way to increase positive time together as a family, increase parental monitoring, and
let Todd know that his mother enjoyed his company.
Session four: Nancy and Todd came in to the meeting concerned over the fact that
Todd’s high school had said he could not return due to multiple suspensions for truancy. I
recommended that the family start the paper work for Todd’s referral to the organization that
helps individuals with developmental delays. If funding was approved, the organization could
assign Todd a vocational caseworker to help him find work if he was not going to be in school.
In the meantime, I told the family I could add some vocational skills to my work with Todd. For
the remainder of the session, the family told me about their first movie night which they had
enjoyed.
FAMILY TREATMENT OF ADHD AND FASD 87
I asked Todd to fill out his first session rating form for our first month of work with him
and his mother. Todd put himself at 7/10 for relationship, 6/10 for goals and topics, 7/10 for
approach or method, and 7/10 overall. Todd said that attending sessions was tough for him and
that he found it cumbersome at times, but he felt some good things were coming out of the work
together.
Month Two
After the first month of working with Nancy and Todd, I felt positive that there had been
progress from the time of intake. Nancy and Todd also noted this progress in their evaluations
and verbal feedback. Nancy said she felt more supported having access to individual counselling
and the parent group. She also felt that she had started to have a better understanding of Todd’s
behaviour. Todd said his mom was making some changes at home and that it made life easier
for him, which in turn made him less anxious and angry. However, there were still problems and
Nancy and Todd easily defaulted back to old conflict cycles, but there were times when they did
follow their new learning adeptly which was encouraging. I knew that repetition would be key
as well as ongoing feedback and coaching.
Nancy’s sessions. I had planned to cease my weekly individual work with Nancy after
the first month, but the new learning had been slow so I asked her if we could continue for a few
more individual sessions, which she was willing to do. Nancy did well with the structure of
attending therapy sessions. She could vent her frustrations and problem-solve around here
experiences rather than take them out on Todd.
Session five: I asked Nancy about her and Todd’s use of alcohol and marijuana. Nancy
said that it was still ongoing. I showed Nancy some pictures online of what long-term use of
substances could do to the brain. Then I explained to Nancy that substance use was very
FAMILY TREATMENT OF ADHD AND FASD 88
problematic for Todd’s because his brain was already sensitive. I recommend that if Todd had
his friends over rather than going out she could monitor his use of substances. Nancy said that
she was careful not to use substances around Todd, but at another time in the conversation, she
admitted to buying alcohol and leaving it accessible at the house. I attempted to help Nancy
understand that to help her son; she would have to lessen or cease her relationships with alcohol
and marijuana, and help promote pro-social activities to Todd.
Session six: Nancy and I continued to go over principles of behaviour modification. I
taught her how to alter the environment around Todd to change his challenging behaviour.
Nancy and I continued to rehearse management of problematic situations that she found herself
in at home with Todd. Nancy wanted to set up a simple consequence chart for Todd after a
discussion around the dangers of inconsistent and intermittent discipline at the parent group. We
talked about fair and simple consequences versus punishment or consequences that would set
Todd up to fail. I explained to Nancy that consequences needed to be immediate and relevant for
Todd to have a chance to relate them to his undesirable behaviour. I recommended
consequences that would keep Todd engaged and active rather than taking away privileges or
keeping him in his room. In addition, if Todd could do patterned repetitive movement like
chopping wood, going for a run, moving debris in the backyard, it would help with his self-
regulation skills and abilities.
Session seven: To help her cope better with the stress of parenting, I led Nancy through
a relaxation exercise that focused on deep breathing and visualizing a relaxing, peaceful place.
Nancy enjoyed the exercise, and requested a copy on a CD that she could play at home which I
later arranged. We also did a brainstorming exercise on chart paper of other ways she could
FAMILY TREATMENT OF ADHD AND FASD 89
practice self-care when she had a frustrating day. I emphasised that she could learn to role model
healthy ways to cope with stress for Todd that did not require the use of substances.
Session eight: Nancy informed me that the court date had been for Todd’s sentencing
hearing had been set for the following month. She asked if I would accompany her and Todd to
court to assist her and Todd, and to meet Todd’s probation officer. I agreed stressing that
sentencing by a Judge should recognize the presence of Todd’s brain dysfunction. I asked Nancy
to sign an information release to the legal aid lawyer that the family was using so I could ensure
that the lawyer was aware of the impact of Todd’s conditions on his adaptive functioning.
Nancy also told me that she did not think she could come manage coming in to see me
twice a week and attend the parent group, as she was starting a new housekeeping job. I told her
that we could focus on the joint sessions between her and Todd moving forward, but that she
could book time with me as needed for herself. I reminded her that I needed her support to
ensure that Todd was practicing new skills at home. She asked if she could call me in regards to
issues surrounding Todd if needed and I agreed to this.
Nancy also filled out her second session rating form for our second month of work. She
placed herself at 9/10 for relationship, goals and topics, approach or method, and a 9/10 overall.
Nancy said she felt supported by the therapeutic relationship and felt that she had learned a great
deal about how Todd’s brain works in addition to new parenting skills.
Todd’s sessions. I asked Todd to start seeing me on his own once a week on top of the
joint sessions with his mother. I assured him that our sessions would only be thirty minutes in
length. I wanted to begin educating Todd on how his brain worked and help him find ways to
work within his environment for better success. Exercises for self-regulation were imperative. I
also wanted to help him realize his strengths and possible pathways for his future.
FAMILY TREATMENT OF ADHD AND FASD 90
Session one: My first individual session with Todd was deliberately set-up to be
informal. We spoke about his interests and strengths and what aspects of his life were currently
going well rather than focus on deficiencies. I asked Todd to draw a picture of what he thought
his brain looked like as an icebreaker. Todd and I had a simple conversation about
ADHD and how it affects the brain in both positive and negative ways. Todd could identify with
many of the examples I used. I asked Todd what he would like to work on in our next session
and he suggested strategies for dealing with anger. I decided to put vocational skills on hold to a
later date. I told Todd that if I gave him homework I would let his mother know so she could
help him practice at home and he agreed to this verbally and in writing.
Session two: Todd and I started the session by looking at a diagram of the anger arousal
cycle. I used simple terms to explain to Todd how anger can impede rational thoughts and
actions. I asked Todd to close his eyes and describe where he feels anger in his body while
thinking about a scenario that frustrates him. We also did some worksheets designed for young
children to identify where Todd feels the first signs of anger in his body. He noted that his hands
clenched when he became irritated and frustrated. I asked Todd to try breathing deeply when his
hands started to clench and to take a walk as a time-out to calm down. We did a deep breathing
exercise where Todd imagined a balloon inflating and deflating in his abdomen.
Session three: Todd was eager to share the fact that he had been in an argument with
some friends a few days prior and had walked away rather than use physical force. I offered him
encouragement and positive feedback about this choice. This event prompted an unplanned
discussion around healthy friendships and boundaries. Todd and I did a diagram together that
identified which of his peers were safe to be around, and which were not. We discussed ways
that the two groups might act differently. I asked Todd to think of the best friend he ever had,
FAMILY TREATMENT OF ADHD AND FASD 91
and together we made a list of qualities that good friends possess. We then compared the list
against the friends in town who often enlist Todd to participate in troublesome and antisocial
activities.
Despite Todd’s recognition that many of the people he considered friends did not have
his best interests at heart, Todd wanted to believe that everyone was his true friend and liked the
feeling of belonging that his group of friends in town gave him. I asked Todd to keep some of
the work we had done in mind and challenged him to think about joining an activity in town to
meet new people. He mentioned that there was drop-in basketball at the high school gym once a
week that he would be open to trying out.
Session four: Todd said he was nervous about his upcoming court date and that thinking
about being in front of a Judge was triggering his anxiety. I drew him a diagram of how thoughts
can affect feelings and I role-played examples of distorted thinking. We also did a progressive
muscle relaxation exercise tailored to children with special needs. The exercise used tangible
visualizations that I thought Todd would enjoy and be able to remember when practicing on his
own. Todd and I also talked about using a thought stopping technique in his mind when he
experienced running negative thoughts. Todd said he would try the strategy out between
sessions.
I also asked Todd to fill out his second session rating form for the second month of work
with him and his mother and for his first month of individual work. Todd put himself at 9/10 for
relationship, 7/10 for goals and topics, 8/10 for approach or method, and 8/10 overall. Todd said
that he was enjoying counselling more now that he had his own session times. He felt that I was
open to his ideas around topics he wanted to work on. He stated that he still found the work hard
but he had learned a few new things that he found helpful.
FAMILY TREATMENT OF ADHD AND FASD 92
Joint sessions. The plan was to continue working on communication, mediation and
enhancing attachment between Nancy and Todd in month two.
Session five: I checked-in with Nancy and Todd about whether they had heard back
from the developmental disabilities organization. Nancy said that they had contacted her and set
up an appointment but she had missed it. I explained to both her and Todd the advantages of
connecting with the organization now and for the future, and Nancy promised she would call
back. However to prevent further delay, I asked Nancy for permission to contact the caseworker
on her behalf to set-up a time when she could come over to one of our sessions and meet the
family. Nancy was agreeable to this option. I also enquired how family dinner and movie night
was progressing and Nancy said that they had done it a few times, but forgot one week. I
reminded both Todd and Nancy to make it a priority and schedule other events around the
evening.
Todd complained that Nancy wanted to rearrange his room and go through his things.
Nancy said she was attempting to reduce the clutter in Todd’s room and make it a more soothing
environment. I suggested that Todd and her approach this as a joint project, and that Todd have
time to put away any personal belongings before Nancy and him began. Both mother and son
accepted this idea.
Session six: I had Nancy and Todd do some listening exercises, including one where
they each played the speaker and listener. I adapted the exercise to be much shorter than the
original instructions so that each listener only had to paraphrase and reflect a few statements
rather than five minutes of dialogue. Nancy and Todd role-played a contentious issue from their
relationship that we had brainstormed and recorded on the white board to maintain focus.
FAMILY TREATMENT OF ADHD AND FASD 93
Session seven: This session focused on attachment exercises and self-esteem
interventions. For example, Nancy and Todd each stated one thing they appreciated about the
other and shared it aloud. Next, they had to come up with a positive memory of one another
from any time in the past and recount it. The goal was to place focus on positive associations
rather than conflict. I also did some psychoeducation around communication roadblocks.
Session eight: Todd and Nancy did not show-up for session eight. Later that day I was
able to reach Nancy on the phone. Nancy said that she had been called into work and had not
been able to call to cancel. I mentioned to Nancy that Todd wanted to pursue drop-in basketball
at the community centre. Nancy said she supported the idea after I extolled the benefits of
physical exercise for Todd (e.g., to reduce anxiety, to avoid unsavoury peers, to help with self-
regulation, to raise self-esteem). However, because Todd and Nancy lived out of town, Nancy
would have to commit to driving Todd each week, unless he could get into town on his own.
She said she was willing but I was uncertain that she would be able to maintain this commitment.
Our next joint meeting was rescheduled.
Month Three
At the start of my third month working with the family, Nancy received a package from
the FASDs assessment centre with dates for Todd’s assessment. The centre also sent a large
package for Nancy to fill out requiring detailed background information on her and Todd. Nancy
was happy about the assessment but also apprehensive. The reality of the assessment triggered
Nancy’s feelings of guilt and shame around drinking in pregnancy. I encouraged her to share her
feelings at the parent-to-parent group for additional support. The family was also feeling
stressed about the outcome of Todd’s upcoming court date.
FAMILY TREATMENT OF ADHD AND FASD 94
Joint sessions. We agreed to focus on joint planning sessions for the month to complete
the assessment centre paperwork and prepare for court. This also offered me the opportunity to
connect with Todd’s probation officer and legal aid lawyer.
Session nine: Nancy, Todd and I met to complete the assessment centre package.
Completing the forms took the majority of the session, but a lot of the required information was
already in Nancy and Todd’s case file from earlier information they had brought in. I
encouraged Nancy and Todd to discuss their feelings about the upcoming assessment. Todd
stated that on one hand he would like to know the reasons he struggled with life so much, but on
the other hand he did not want to be labelled as “stupid”. I reflected Todd’s feelings and
normalized his experience. However, I assured Todd that the assessment would look at his
strengths and weaknesses and that he could expect more positive than negative to come from a
better understanding of his brain. Nancy used the time to talk to Todd about her feelings of guilt
and apologize for everything they had been through as a family. Todd did not get angry and was
empathic toward Nancy despite his own frustrations.
Session ten: Since seeing Nancy and Todd last, I spoke to the community living agency
on their behalf and requested that a representative come to the agency to meet with Nancy and
Todd to discuss what services they could provide the family. The case manager was able to
come to my next session with Nancy and Todd. She informed us that their agency could apply
for funding to connect Todd with a vocational caseworker and with parent relief for Nancy.
Nancy and Todd were both interested in the options therefore the paperwork was completed to
secure these resources.
Session eleven: Nancy, Todd and I met Todd’s probation officer to speak with him about
court the following week. Before this session, I had spoken on the phone with Todd’s legal aid
FAMILY TREATMENT OF ADHD AND FASD 95
lawyer and with his probation office to ensure they were fully aware of his ADHD and potential
FASD and how these conditions could affect his behaviour. I wanted to ensure that Todd had fair
sentencing. At Nancy’s request, I asked Todd’s lawyer to suggest to the Judge that Todd attend
a residential program for adjudicated youth where he could get uninterrupted counselling and
support. Todd’s probation officer and I went over what Todd and Nancy could expect from
court, and coached Todd on how to act (i.e., respectful, make eye contact, dress appropriately).
Session twelve: Nancy and Todd came in for an unscheduled visit because of a large
argument they had had in their car on the way to a neighbouring city. Nancy was scared because
Todd expressed some suicidal ideation during the conversation. Todd said that at the time he
was angry and feeling hopeless but by the time of the session he was feeling better. I reminded
them both that it was normal to feel overwhelmed, especially with all the work they were both
doing in counselling. I did a risk assessment with Todd and he did not appear to have any
specific suicide plan concocted. It appeared to me that under emotional duress Todd had not
really thought out the repercussions of his threats.
I thought it was important to create a safety plan so we all discussed and drew up a plan
for the next time Todd felt suicidal. We mapped out whom to call for help or support and what
resources to access. I reminded Nancy to call a time out when she was angry with Todd rather
than push him or berate him. I suspected that emotional overload in a confined space drove
Todd to the place where he made the suicidal threat. I also reminded Todd to ask for a time out,
and focus on his relaxation techniques and deep breathing in moments of crisis.
Session thirteen: I met Todd, Nancy and Todd’s probation officer at the courthouse for
Todd’s hearing. Todd and I did some breathing exercises and role rehearsals while he was
waiting for his turn. In the end, Todd was sentenced to another year of probation because of his
FAMILY TREATMENT OF ADHD AND FASD 96
neurological impairments. The judge recommended that during the year Todd attend some type
of residential program and gave Todd a list of new probation orders. After sentencing, Nancy
and Todd came back to my office so we could go over everything that had happened in the day.
I went over the new probation rules with Todd but he found them too confusing and detailed for
his comprehension, therefore I wrote out a simplified version with visuals that Nancy could put
up at the house for Todd.
I gave Nancy and Todd evaluation forms for the past month to complete. Todd put
himself at 9/10 for relationship, 8/10 for goals and topics, 8.5/10 for approach or method, and
8/10 overall. Nancy put herself at 10/10 for relationship, 9/10 for goals and topics, 9/10 for
approach or method, and 9/10 overall. Both Todd and Nancy found my support invaluable in
preparation for court, helping them with the assessment paperwork, and coming up with a plan
for them in regards to suicidal ideation. Since Todd and I were not doing individual counselling
work, I believe he felt that the month had been less intense for him, even though there had been a
lot going on outside of session.
Month Four
At the start of month four, Todd and Nancy travelled to get Todd’s assessment for a
FASD completed. The assessment appointments occurred over two days and Todd saw a
psychologist, psychiatrist, paediatrician and social worker.
Todd’s sessions. The month after court, while waiting for Todd’s assessment results, I
wanted to do some repetition of previous learning. I planned to do some additional modified
CBT with Todd and address his substance use.
Session five: Todd and I did a review session of all the things we had worked on up to
his court date. We reviewed strategies for anger management, dealing with anxiety and
FAMILY TREATMENT OF ADHD AND FASD 97
brainstormed ways for Todd to spend more time developing his strengths and less time with
unsavoury peers. We did two worksheets on self-identifying strengths and interests. Todd
mentioned he had made drop-in basketball once and had really enjoyed it. I encouraged him to
keep going and to make it a priority. Unfortunately, Nancy was not always reliable in terms of
giving Todd a ride into town. We went over his probation rules again in an effort to get them
ingrained in his memory. Todd and I also discussed his experience at the assessment centre.
Session six: Todd and I did an exercise on the computer related to distorted thinking and
positive affirmations. Todd and I discussed again how distorted thoughts can affect they way
one perceives a situation and how negative thoughts can lead to feelings of anger and anxiety.
Todd identified that he was a black and white thinker, and that he always assumed the worst was
bound to occur in any given situation. We talked about reframing cognitions into positive
affirmations (i.e., self pep talks) for the purpose of self-regulation. When returned to a baseline
of functioning, Todd could then try to problem solve. However, I knew problem solving was
very difficult for Todd so we did some pre-emptive work around what to do when he could not
get a hold of Nancy. We identified three simple things she and Todd could do in the moment.
Session seven: I asked Todd if he would be willing to do some work around his use of
substances. Todd was agreeable so we did some simple worksheets on how drugs and alcohol
negatively affect the brain and body. The worksheet had Todd cutting and pasting his answers to
link concepts keeping him kinaesthetically engaged. I also did some psychoeducation with Todd
on the subject and we looked at some online resources. I empathized with Todd around the fact
that substances made him feel better in the moment and that using substances had been a survival
skill for him. However, the goal would be to use healthy activities to substitute for substance use
over time step by step. We spoke about the benefits of physical exercise as an outlet, and its
FAMILY TREATMENT OF ADHD AND FASD 98
affects on serotonin levels. Overall, the goal was harm reduction since Nancy and Todd were not
open to any kind of detoxification or rehabilitation program.
Session eight: Todd did not show up for his session. When I phoned the house, Nancy
said he had gone out, but that they would both come in after the assessment results. I reminded
Nancy to focus on the positive with Todd and to call me with any problems.
Joint sessions. A few weeks later, the results of the assessment came back. Nancy and
Todd travelled back to the assessment centre for the discharge summary and I attended via
teleconference. Todd was diagnosed with Alcohol-Related Neurodevelopmental Disorder
(ARND), on the FASDs spectrum of conditions, with a code of 1134. His adaptive skills were at
the first percentile of functioning and the assessors confirmed that his ARND and ADHD likely
caused his EF and expressive language deficits. The assessors supported the fact that Todd’s
ADHD and challenging behaviours were likely related to both prenatal and postnatal insults.
The assessors made recommendations that Todd (a) have a structured learning
environment with realistic expectations, goals, and responsibilities that target his strengths and
skills; (b) be given additional time to process information or complete tasks; (c) have access to
manipulatives, pictures, and other visuals; (d) be given concrete one-step directions; (e) have
access to environments with minimal distractions and reduced sensory stimulation; (f) have a
structured, predictable daily routine; (g) have role models that demonstrate proper ways to act
and/or be taught social skills; and (h) consider drug and alcohol treatment and attend Narcotics
Anonymous (NA) and/or Alcoholics Anonymous (AA).
Session fourteen: Todd and Nancy came in together for a post-assessment visit. I went
over the assessment results with Todd and Nancy in simple language. I emphasized the family
strengths and Todd’s individual strengths. I normalized their feelings and worries about the
FAMILY TREATMENT OF ADHD AND FASD 99
future. It reminded them that the diagnosis was not a complete surprise, as we had all been
working together assuming that a FASD was a real possibility. In fact, we had already been
doing the majority of the recommendations put forth by the assessment team. The assessors had
noted that Todd had strong mechanical inclinations, and Todd was pleased about this. I also
gave the family information about the provincial disability funding that Todd could access at age
18. I further recommended that Nancy take Todd to an AA or NA meeting.
In regards to the counselling session rating for the month, Todd put himself at 9/10 for
relationship, 7/10 for goals and topics, 7/10 for approach or method, and 8/10 overall.
According to Todd, things were still going well for him and the sessions were useful but he was
finding the individual meetings onerous. I suggested that perhaps we focus on joint sessions
again for the near future and he agreed. Nancy put herself at a 10/10 for relationship, 9/10 for
goals and topics, 9/10 for approach and method, and 9/10 overall. Nancy said she had been
attending the parent group each week and was fining it a helpful outlet for her feelings around
Todd’s diagnosis and her feelings of guilt and shame. She stated she really appreciated my
support and assistance.
Month Five
With a focus back on joint sessions, I wanted to do more work with Nancy and Todd on
FASDs and their affect on the brain and behaviour. I also anticipated word on whether the
funding had been approved for a vocational caseworker and parent relief.
Joint Sessions.
Session fifteen: I did a psychoeducation session with Nancy and Todd on FASDs. We
went over the neurobehavioral symptoms of FASDs and their affect on behaviour. I spoke to
Todd about self-advocacy and gave him ideas on how to ask others to slow down their speech, or
FAMILY TREATMENT OF ADHD AND FASD 100
write things down for him. I talked with Nancy again about supervision, structure, and simple
one-step instructions. We went over a worksheet on common misinterpretations of behaviour in
those with FASDs. Todd found many things he could personally relate to on the worksheet,
which prompted further discussion.
Nancy and Todd said that they had gone to a NA session together. Nancy said she was
proud of Todd as he stood up and told his story to the group. The group also seemed to
invigorate Todd as Nancy said he could not stop talking about how much he could relate to the
other members. I praised the family for making such a large step in a positive direction.
Session sixteen: Nancy, Todd and I met again with the case manager from the
developmental disabilities association. Todd and Nancy’s funding was approved and Todd was
going to be assigned a vocational caseworker named Andrea to assist him in finding and
maintaining employment. Nancy could also choose a foster parent in town to provide parent
relief for her up to 20 hours a month and the association would cover the costs involved. Andrea
came in to meet Todd and arranged to an intake assessment for him later that week. Nancy and
Todd also signed release of information papers between Andrea and I so that I could give her
information on how Todd’s ARND and ADHD affect his vocational abilities.
Session seventeen: Between sessions, I had contacted Todd’s probation officer as I felt
that the supervision from probation had been poor and ineffective. At this time, I was told that
Todd had been assigned a new probation officer and she would be coming to town the following
week to meet with the family. I suggested we all meet any my office. The new probation
officer, Bridget, was keen to help Todd adhere to, and fulfill his probation requirements. She
said she would like to see Todd attend a four-month residential program for adjudicated youth
four hours north of town.
FAMILY TREATMENT OF ADHD AND FASD 101
The program followed a wilderness camp model that is highly structured and focused on
building self-esteem and individual responsibility. The program combined behaviour
modification and reality therapy with access to group counselling, life skills, survival skills,
community service, educational credits, fitness and substance detoxification. Bridget brought a
promotional DVD that we all watched as group.
At first, Todd was quite upset and resistant to the idea. However, Nancy thought it
looked like a great program for Todd and believed he could be successful at it. Bridget said she
was submitting the referral for approval. She suggested that I work with Nancy and Todd on the
realities of the situation, and help them accept Todd’s upcoming attendance as the next intake
date was two weeks away. She left us with all the necessary paperwork to complete.
Session eighteen: Todd was adamant that he did not want to attend the program. Nancy
and I focused on the positive aspects of the program, while acknowledging that it would be
challenging for Todd. I emphasized to Todd that the program would allow him to get all his
needs met in once place and although four months seemed long, the program was temporary.
Visitors could see participants every two weeks, so Nancy promised she would do the drive
twice a month to visit him. I gathered information to send to the program on Todd’s diagnoses
so the camp staff would be aware of his limitations.
Sessions nineteen to twenty: Personally, I agreed that the program would be a good
option for Todd. I felt that Todd fared best in a highly structured environment, and as best as
Nancy tried, she had not been able to give Todd all the supervision and monitoring that he
needed. I had not anticipated that our work together would come to such an abrupt halt so I
decided to spend our next couple of sessions reinforcing prior learning. I also let his vocational
caseworker Andrea know that her work with Todd would need to be put on hiatus until he was
FAMILY TREATMENT OF ADHD AND FASD 102
back in town. I helped Nancy and Todd prepare for the transition and said my goodbyes to Todd
for the time being. With everything going on neither Nancy nor Todd had time to fill out their
end of month evaluation forms; however, they noted their satisfaction verbally.
Months Six to Nine
During months six to nine Todd attended his wilderness program. I sent him encouraging
emails and kept in touch with Nancy over the phone to receive updates on how Todd was
progressing. Despite my objections, Nancy stopped attending the parent group at this time. She
felt that she had nothing to talk about with Todd away even though I encouraged her to come to
the group and share Todd’s successes at camp.
Todd experienced peaks and valleys in the program but managed to earn enough
behavioural contingencies to garner free time and some visits into the city. Nancy faithfully
visited him every two weeks to help him with morale. Overall, Todd did very well in the
program. He trained to run a marathon and successfully completed it. He also won the award for
“Most Improved Camper”.
The week before Todd was to come back to town, an integrated case management
meeting was held to discuss Todd’s transition back to the community. Todd’s probation officer,
vocational caseworker, Nancy and myself were all present. Nancy was keen to mimic the
structure and schedule of the camp for Todd when he came back, and make sure he continued his
exercise and daily activities. That said, Nancy had trouble coming up with ideas and we all
realized that with the supports of the wilderness program removed, Todd would likely revert to
his old behaviour.
Therefore, I suggested that Todd attend a new program that had launched in town that
taught vocational and life skills to at-risk youth in a small classroom setting. This type of
FAMILY TREATMENT OF ADHD AND FASD 103
program would give Todd structure to his days. The program was four months long, limited to
ten participants, and paid minimum wage for 30 hours of work a week. I asked Nancy to ask
Todd if he would be interested in this, and if so I would put the referral through. The only
downside was that the program did not start for another six weeks. Bridget said she could help
support Todd to attend the program and do the necessary work around submitting his application.
Month Ten
Todd came back to town looking extremely healthy and clear of mind. He was excited
about his accomplishments and the possibility of attending the youth employment skills course.
He was eager to continue his running program and said he had a number of goals he wanted to
achieve.
Todd wanted to focus on vocational skills with his caseworker and Nancy felt she had
enough support from parent relief and the parent group. Both Nancy and Todd felt that they did
not want to return to individual or joint counselling at this time. I wanted to support the family
in their choice but I also warned that the removal of supports could sometimes result in relapse.
In the end, it was the family’s choice, so I asked the pair to come in to do a discharge report and
final evaluations of the work we had done together. I let them know that we could resume
counselling in the future if they desired.
Months Eleven to Fourteen
During these months, Nancy called me a few times to give me updates on her and Todd’s
situation. Todd did attend the youth employment skills program and did well for the first two
months. Unfortunately, his behaviour slipped as soon as he started socializing with his former
peer group. He started using substances again and his motivation to exercise diminished. At this
time, Nancy asked if they could resume counselling. I referred Nancy and Todd to my incoming
FAMILY TREATMENT OF ADHD AND FASD 104
replacement as I was leaving my position to move to another city. Andrea continued to work
with Todd during this time. Todd completed three of the four months of the youth employment
skills program before leaving it all together. After the program ended, he decided to move to the
coast to live with an old girlfriend.
Results
Case Impressions
Successes. Nancy and Todd came to counselling with a long history of challenges.
When the family first came to counselling, Nancy was feeling hopeless as a parent, and Todd’s
behaviour was escalating to harmful levels. Through our work together, I believe the family’s
functioning became more stable as evidenced by a reduction in the intensity of their conflicts, as
well as an increase in knowledge of how Todd’s condition affected his adaptive skills and
behaviour. Todd showed on a few occasions that he could use the self-regulation strategies that I
taught him to reduce his anger and anxiety. Nancy was able to get the encouragement and
support she needed to deal with the frustrations of raising a child with special needs through our
work together and via the parent group. Nancy also started practicing self-care, which greatly
enhanced her coping abilities.
Nancy and Todd felt they had made progress and learned new skills. The therapeutic
relationships proved to be the most valuable aspect of the therapy process, and Nancy and Todd
felt they had support and encouragement to face their challenges. Both Nancy and Todd seemed
to have increased self-esteem. Todd was better able to advocate for himself as demonstrated by
his ability to ask for things to be written down so he would not forget anything. Todd was also
able to volunteer to attend the youth employment skills course and try it out after being out of
town for four months. Nancy was willing to return to the parent group after a long absence.
FAMILY TREATMENT OF ADHD AND FASD 105
Most importantly, when Todd and Nancy first came to session they did not really understand
why Todd struggled with life so intensely, and through the course of therapy they were able to
receive an assessment and a proper comprehensive diagnosis for Todd, that would ensure them
proper supports in the years to come.
Nancy and Todd’s relationship, although never perfect, was better than when they first
came to counselling. Nancy had gone to visit Todd every two weeks as promised while he was
away, and both had made an effort to do activities together while in counselling. The pair fought
less abusively and Nancy had reduced her demands, according to both her and Todd. Overall,
Nancy and Todd rated their relationship with me, and the goals we had worked on together
positively. All their self-reported session evaluation marks placed the work at an average of
8.5/10.
Challenges. Despite these successes, there were also a lot of setbacks and challenges.
When Todd went to wilderness camp, the flow of our therapy sessions was broken and the
family was reluctant to get started again when Todd was back in town. Todd did very well when
supports were in place and he could receive external prompts, coaching, reassurance and
encouragement. However, throughout the course of therapy he was not able to generalize new
learning out of session on a consistent basis. I believe this was related to his ADHD and ARND
and the issue of flow-through or inconsistent memory. I struggled at times with the line between
being a counsellor versus being a caseworker in such a small rural community. Often the lines
blurred when therapeutic work was sidetracked to deal with more immediate and pressing
external concerns.
I felt like I was unable to do the amount of repetition and practice that I would have liked
to do to help Todd and Nancy commit new learning to memory. Todd did well with systematic
FAMILY TREATMENT OF ADHD AND FASD 106
instructions but he struggled on a daily basis with peers and the community when making
decisions on his own. Todd needed a constant external brain to function well, in the form of a
capable adult mentor, which is why I believe he did so well in residential programs where he had
access to workers all day and night.
Another area we had little success in was getting Todd to reduce his substance use. Todd
was forced to give up substances at camp but he went back to them as soon as he could. His
substance use was so routine that it was second nature as a coping mechanism for him and I
believe he needed a long-term substance rehabilitation program. In retrospect, I believe I should
have pushed for Nancy and Todd to consider this option more stridently.
Case Recommendations
During our last session, Todd, Nancy and I reviewed all the work and learning we had
done together. I wrote out every topic we had covered on a white board and we went over past
evaluations. I made the following recommendations: (a) that Todd should continue to see
Bridget his vocational caseworker for support (b) that Todd attend the youth employment skills
course to keep structure to his days; (c) that Nancy take advantage of parent relief and to come
back to the parent group sessions; (d) that Nancy and Todd resume their movie night once a
week; (e) that Todd continue with his running or return to basketball for health, stress relief, and
avoidance of substances; (f) that Todd continue to enrol in any structured programs that were
available to him; (g) that Todd continue to practice his coping mechanism for stress, anger, and
anxiety (h) that Todd consider some type of substance abuse rehabilitation program and/or return
to NA or AA right away; and (i) that Nancy continue to practice her new parenting skills and
continue to adapt her expectations of Todd to his developmental age and abilities.
FAMILY TREATMENT OF ADHD AND FASD 107
Discussion
Personal Reactions to the Case
Working with Todd and Nancy was one of the biggest challenges of my life. At times, I
felt frustrated by the family’s lack of progress and with Nancy’s lack of ability to support Todd
adequately. Then, I would remind myself of the neurological dysfunction that I was working
with and could reframe my thoughts and get back to work. There were also times when I
lamented that fact that Todd struggled due to alcohol exposure in utero and growing up in an
abusive household, both technically preventable situations. I had to balance the line between
frustration and empathic understanding.
What I Learned from the Case
I learned a vast amount about ADHD and FASDs, which opened my eyes to a new world
of understanding others. I came to understand that brain dysfunction might manifest as
challenging behaviours. I learned the power of encouragement, building on strengths and
operating from a family-centred perspective when working with at-risk families. I believe that
Nancy and Todd felt truly supported by our work together.
Personal Implications
I had to engage in a high degree of self-care during this case, as it was demanding and
there were often little tangible results of progress. It was an important learning experience to
release my natural inclination to base my own pride of accomplishment off visible results. I had
to remind myself that the work was not about me, but rather it was about the small improvements
that the clients made at their own pace.
I also leaned on my supervisor a great deal, and my colleagues at work, to debrief and
brainstorm solutions and strategies. I realized the value of reaching out to others when working a
FAMILY TREATMENT OF ADHD AND FASD 108
difficult case. I was also able to attend many workshops and conferences on ADHD and FASDs
that broadened my horizons and made me a more effective counsellor.
Implications for my Clients
Even though Nancy and Todd did not want to resume counselling after Todd came back home, I
think the work we all did together changed the way Todd and Nancy viewed the counselling
process. I think that in the future both Todd and Nancy would be more willing to seek out and
ask for help of this nature. Todd and Nancy were also able to learn a significant amount about
the nature of ADHD and FASDs. I believe Todd and Nancy will have a greater capacity to self-
advocate around getting their needs met in the future. Although their relationship was still under
construction when we ceased counselling, I feel hopeful that they will continue to see each other
from a more positive perspective. Nancy and Todd self-reported in their counselling assessments
that they had experienced positive changes in their lives and that their satisfaction with therapy
increased with each passing week.
Recommendations for other professionals. When working with a family affected by ADHD or
a FASD the first goal is to develop a trusting relationship, as all potential for future success and
progress will arise from that foundation. Future therapists need to adjust their expectations for
progress and achieving goals and focus more on building strengths and internal resources in
clients like Todd and Nancy. Multimodal counselling interventions will allow the most
flexibility. Finding way to create structure and supervision will also help keep crises contained.
I would also recommend that workers not get discouraged by missed appointments, unexpected
crises, relapses and regressions. The most important thing is that the family can count on their
worker to be there when they need their assistance.
FAMILY TREATMENT OF ADHD AND FASD 109
Implications for the Field
I think Nancy and Todd also came to realize that many of Todd’s issues were lifelong and
related to his disability. Unfortunately, there are simply not enough lifelong supports or
programs in place for those with ADHD and FASDs (Rutman, LaBerge, & Wheway, 2002).
FASDs are a major public health concern and there needs to be more education around
prevention of the condition, better programs and support for managing the condition, and more
access to proper and timely assessment for both children and adults.
Based on my literature review of ADHD and FASDs, Nancy and Todd’s sessions were
quite consistent with my expectations. A family-centred strengths-based framework was the
foundation. Behaviour therapy, modified CBT, psychoeducation, life and social skills training
were all useful for Todd. Nancy did well with parent-teen mediation, BPT and CHM
interventions. Getting the family support and enhancing their coping abilities allowed them to
function better with each other and in society, and to feel better about their lives, even when their
actual problems did not diminish as greatly as they would have desired.
FAMILY TREATMENT OF ADHD AND FASD 110
References
Abikoff, H. (1991). Cognitive training in ADHD children: Less to it than meets the eye.
Journal of Learning Disabilities, 24(4), 205-209. doi: 10.1177/002221949102400404
Abikoff, H., Hechtman, L., Klein, R., Weiss, G., Fleiss, K., Etcovitch, J., . . . Pollack, S. (2004).
Symptomatic improvement in children with ADHD treated with long-term
methylphenidate and multimodal psychosocial treatment. Journal of Child and
Adolescent Psychiatry, 43(7), 802-811. doi: 10.1097/01.chi.0000128791.10014.ac
Acro, J. L., Fernandez, F. D., & Hinojo, F. J. (2004). Attention deficit hyperactivity disorder: A
psychopedagogical intervention. Psicothema, 16(4), 408-414. Retrieved from
http://www.psicothema.com/psicothema.asp?id=3011
American Academy of Pediatrics. (1999). Clinical practice guidelines: Diagnosis and evaluation
of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105(5), 1158-1170.
Retrieved from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;105/5/1158.pdf
American Psychiatric Association [APA]. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington, DC: Author.
Alati, R., Almamun, A., Williams, G. M., O’Callaghan, M., Najman, J. M., & Bor, W. (2006).
In utero alcohol exposure and prediction of alcohol disorders in early childhood: A birth
cohort study. Archives of General Psychiatry, 63(9), 1009-1016.
Alati, R., Clavarino, A., Najman, J.M., O’Callaghan, M., Bor, W., Mamun, A. A., & Williams,
G. M. (2008). The developmental origin of adolescent alcohol use: Findings from the
Mater University Study of Pregnancy and its outcomes. Drug and Alcohol Dependency,
98(1-2), 136-143. doi: 10.1016/j.drugalcdep.2008.05.011
Astley, S. J., & Clarren, S. K. (2000). Diagnosis the full spectrum of fetal alcohol-exposed
FAMILY TREATMENT OF ADHD AND FASD 111
individuals: Introducing the 4-digit diagnostic code. c(4), 400-410. doi:
10.1093/alcalc/35.4.400
Baer, R., & Nietzel, M. (1991). Cognitive and behavioral treatment of impulsivity in children: A
meta-analytic review of the outcome literature. Journal of Clinical Child Psychology,
20(4), 400-412. doi: 10.1207/s15374424jccp2004_9
Baer, J. S., Sampson, P. D., Barr, H. M., Connor, P. D., & Streissguth, A. P. (2003). A 21-year
longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking.
Archives of General Psychiatry, 60(4), 377–385. Retrieved from http://archpsyc.ama-
assn.org/cgi/content/full/60/4/377
Bagwell, C. L., Molina, B. S., Pelham, W. E., & Hoza, B. (2001). ADHD and problems in peer
relations: Predictors from childhood to adolescence. Journal of the American Academy
of Child and Adolescent Psychiatry, 40(11), 285-292. doi: 10.1097/00004583-
200111000-00008
Barkley, R. A. (1996). Attention-deficit/hyperactivity disorder. In E. J. Mash and R. A. Barkley
(Eds.), Child psychopathology (pp. 63-112). New York, NY: Guilford Press.
Barkley, R. A. (1997). ADHD and the nature of self-control. New York, NY: Guilford Press.
Barkley, R. A. (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and
treatment (2nd ed.). New York, NY: Guilford Press.
Barkley, R. A., Edwards, G., Laneri, M., Fletcher, K., & Metevia, L. (2001). The efficacy of
problem-solving communication training alone, behaviour management training alone,
and their combination for parent-adolescent conflict in teenagers with ADHD and ODD.
Journal of Consulting and Clinical Psychology, 69(6), 926-941. Retrieved from
http://www.sciencedirect.com
FAMILY TREATMENT OF ADHD AND FASD 112
Barlow, D. H. (2005). What’s new about evidence-based assessment? American Psychologist,
17(3), 308-311. doi: 10.1037/1040-3590.17.3.308
Barr, H. M., Streissguth, A. P., Blakely, G. G., Darby, B. L., & Sampson, P. D. (1990). Prenatal
exposure to alcohol, caffeine, tobacco, and aspirin: Effects on fine and gross motor
performance in 4-year-old children. Developmental Psychopathology, 26(3), 339-348.
doi: 10.1037/0012-1649.26.3.339
Barr, H. M., Bookstein, F. L., O’Malley, K. D., Connor, P. D., Huggins, D. E., & Streissguth, A.
P. (2006). Binge drinking during pregnancy as a predictor of psychiatric disorders on the
structured clinical interview for DSM-IV in young adult offspring. American Journal of
Psychiatry, 163(6), 1061-1065. doi: 10.1176/appi.ajp.163.6.1061
Barthel, K., & Nickel, I. (2009). Attachment training: Theory and techniques [Lecture notes].
Williams Lake, British Columbia, Canada: Canadian Mental Health Association.
Beail, N. (2002). Interrogative suggestibility, memory, and intellectual disability. Journal of
Applied Research in Intellectual Disabilities, 15(2), 129-137. doi: 10.1046/j.1468-
3148.2002.00108.x
Benson, B. A. (2004). Psychological intervention for people with intellectual disabilities and
mental health problems. Current Opinion in Psychiatry, 17(5), 353-357. doi:
10.1097/01.yco.0000139969.14695.dc
Benson, B. A., & Havercamp, S. M., (2007). In N. Bouras and G. Hott (Eds.), Psychiatric and
behavioural disorders in intellectual and developmental disabilities (2nd ed.).
Cambridge, England: Cambridge University Press.
FAMILY TREATMENT OF ADHD AND FASD 113
Berg, S., Kinsey, K., Lutke, J., & Wheway, D. (1995). FASNET assessment tool: For use with
children aged 14-18 years (Series #2-AT1418). Surrey, British Columbia, Canada:
FAS/E Support Network.
Bertrand, J. on behalf of the Interventions for Children with Fetal Alcohol Spectrum Disorders
Research Consortium. (2009). Intervention for children with fetal alcohol spectrum
disorders (FASDs): Overview of findings for five innovative research projects. Research
in Developmental Disabilities, 30(5), 986-1006. doi: 10.1016/j.ridd.2009.02.003
Bhatara, V., Loudenberg, R., & Ellis, R. (2006). Association of attention deficit hyperactivity
disorder and gestational alcohol exposure: An exploratory study. Journal of Attention
Disorder, 9(3), 515-522. doi: 10.1177/1087054705283880
Biederman, J., & Faraone, S. V. (2006). Attention-deficit hyperactivity disorder. Lancet, 356,
237-248. doi: 10.1016/S0140-6736(05)66915-2
Biederman, J., Monuteaux, M. C., Doyle, A. E., Seidman, L. J., Wilens, T. E., Ferrero, F., . . .
Faraone, S. V. (2004). Impact of executive function deficits and attention-
deficit/hyperactivity disorder (ADHD) on academic outcomes in children. Journal of
Consulting and Clinical Psychology, 72(5), 757-766. doi: 10.1037/0022-006X.72.5.757
Bohjanen, S., Humphrey, M., & Ryan, S. M. (2009). Left behind: Lack of research-based
interventions for children and youth with fetal alcohol spectrum disorder. Rural Special
Education Quarterly, 28(2), 32-38.
Booth, T., & Booth, W. (1993). Parenting with learning difficulties: Lessons for practitioners.
British Journal of Social Work, 23(5), 459-480. Retrieved from
http://www.supportedparenting.com/parenting/parenting.pdf.
FAMILY TREATMENT OF ADHD AND FASD 114
Branham. J., Young, S., Bickerdike, A., Spain, D., McCarton, D., & Xenitidis, K. (2009). Does
group cognitive behaviour therapy improve symptoms of ADHD in adults? Journal of
Attention Disorders, 12(5), 434-441. doi: 10.1177/1087054708314596
Brinkmeyer, M., & Eyberg, S.M. (2003). Parent-child interaction therapy for oppositional
children. In A.E. Kazdin & J.R. Weisz (Eds.). Evidence-based psychotherapies for
children and adolescents (pp. 204-223). New York: Guilford Press. Retrieved from
http://pcit.phhp.ufl.edu/Literature/Brinkmeyer&Eyberg2003_new.pdf
Brown, M. B. (2000). Diagnosis and treatment of children and adolescents with attention-
deficit/hyperactivity disorder. Journal of Counselling and Development, 78(2), 195-203.
Retrieved from http://search.ebscohost.com
Brown, J. D., Sigvaldson, N., & Bednar, L. M. (2004). Foster parents perceptions of placement
needs for children with a fetal alcohol spectrum disorder. Children and Youth Services
Review, 27(3), 309-327. doi: 10.1016/j.childyouth.2004.10.008
Brown, R. T., Coles, C. D., Smith, I. E., Platzman, K. A., Silverstein, J., Erickson, S., & Falek,
A. (1991). Effects of prenatal alcohol exposure at school age, II: Attention and behavior.
Neurotoxicology & Teratology, 13(4), 369-376. doi:10.1016/0892-0362(91)90085-B
Burd, L., Carlson, C., & Kerbeshian, J. (2007). Fetal alcohol spectrum disorders and mental
illness. International Journal of Disability and Human Development, 6(4), 383-396.
Burd, L., Martsolf, J. T., & Jeulson, T. (2004. FASD in the corrections system: Potential
screening strategies. Journal of FAS International, 2(e1), 1-10. Retrieved from
http://www.motherisk.org/JFAS_documents/Corrrections_Screenings.pdf
FAMILY TREATMENT OF ADHD AND FASD 115
Burd, L., Selfridge, R., Klug, M. & Juelson, T. (2004). Fetal alcohol syndrome in the US
correctional system. Addiction Biology, 9(2), 109-116. Retrieved from
http://www.motherisk.org/JFAS_documents/FAS_Corrections_REV.pdf
Burd, L., Klug, M. G., Martsolf, J. T., & Kerbeshian, J. (2003). Fetal alcohol syndrome:
Neuropsychiatric phenomics. Neurotoxicology and Teratology, 26(6), 697-705. doi:
10.1016/j.ntt.2003.07.014
Calderon, C. (2001). Resultado de un programa de tratamiento cognitivo-conductual para niño/as
con trastorno por déficit de atención con hiperactividad [Results of a cognitive-behavioral
treatment program for children with attention deficit hyperactivity disorder]. Anuario de
Psicologia, 32(4), 79-98. Retrieved from
http://www.raco.cat/index.php/AnuarioPsicologia/article/viewFile/61693/88460
Caley, L. M., Shipley, N., Winkelman, T., Dunlop, C., & Rivera, S. (2006). Evidence-based
review of nursing interventions to prevent secondary disabilities in fetal alcohol spectrum
disorder. Pediatric Nursing, 32(2), 155-162. Retrieved from
http://www.medscape.com/viewarticle/534041
Cantwell, D. P. (1996). Attention deficit disorder: a review of the past 10 years. Child and
Adolescent Psychiatry, 35(8), 978–987. doi: 10.1097/00004583-199608000-00008
Carnaby, S. (2007). Developing good practice in the clinical assessment of people with
profound intellectual disabilities and multiple impairments. Journal of Policy and
Practice in Intellectual Disabilities, 4(2), 88-96. doi: 10.1111/j.1741-1130.2007.00105.x
Carroll, K. M., & Rousaville, B. J. (1993). History and significance of childhood attention
deficit hyperactivity disorder in treatment-seeking cocaine abusers. Comparative
Psychiatry, 34(2), 75-82. doi: 10.1016/0010-440X(93)90050-E
FAMILY TREATMENT OF ADHD AND FASD 116
Centers for Disease Control and Prevention. (2010, Nov 12). Increasing prevalence of parent-
reported Attention-Deficit/Hyperactivity Disorder among children --- United States, 2003
and 2007. Morbidity and Mortality Weekly Report, 59(44). 1439-1443. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w
Chronis, A., Chacko, A., Fabiano, G., Wymbs, B., & Pelham, W. (2004). Enhancements to the
behaviour parent-training paradigm for families of children with ADHD: Review and
future direction. Clinical Child and Family Psychology Review, 71(1), 1-27. doi:
10.1023/B:CCFP.0000020190.60808.a4
Chudley, A. E., Conry, J., Cook, J. L., Loock, C., Rosales, T., & LeBlanc, N. (2005). Fetal
alcohol spectrum disorders: Canadian guidelines for diagnosis. Canadian Medical
Association Journal, 172(Suppl. 5), s1 – s21. doi: 10.1503/cmaj.1040302
Clarke, A. S., & Schneider, M. L. (1997). Effects of prenatal stress on behavior in adolescent
rhesus monkeys. Annals of the New York Academy of Science, 807(1), 490-491. doi:
10.1111/j.1749-6632.1997.tb51947.x
Clarke, E., Lutke, J., Minnes, P., & Ouellete-Kuntz, H. (2004). Secondary disabilities among
adults with fetal alcohol spectrum disorder in British Columbia. Journal of FAS
International, 2(e13), 1-12. Retrieved from http://www.motherisk.org/FAR/index.jsp
Coggins, T. E., Olswang, L. B., Olson, H. C., & Timler, G. R., (2003). On becoming socially
competent communicators: The challenge of children with fetal alcohol exposure.
International Review of Research in Mental Retardation, 27(2), 121-150. doi:
10.1016/S0074-7750(03)27004-X
FAMILY TREATMENT OF ADHD AND FASD 117
Coles, C. D. (2001). Fetal alcohol exposure and attention: Moving beyond ADHD. Alcohol
Research and Health, 25(5), 199-203. Retrieved from
http://pubs.niaaa.nih.gov/publications/arh25-3/199-203.htm
Coles, C. D. (2003). Individuals affected by fetal alcohol spectrum disorder (FASD) and their
families, prevention, intervention, and support. Retrieved from http://www.excellence-
jeunesefants.ca/documents/ColesANGxp.pdf
Coles, C. D., Platzman, K. A., Lynch, M. E., & Freides, D. (2002). Auditory and visual
sustained attention in adolescents prenatally exposed to alcohol, 26(2), 263-271. doi:
10.1111/j.1530-0277.2002.tb02533.x
Coles, C. D., Platzman, K. A., Raskind-Hood, C., Brown, R. T., Falek, A., & Smith, I. E. (1997).
A comparison of children affected by prenatal alcohol exposure and attention deficit,
hyperactivity disorder. Alcoholism: Clinical and Experimental Research, 21(1), 150-161.
doi: 10.1111/j.1530-0277.1997.tb03743.x
Conners, N. A., Bradley, R. H., Mansell, L. W., Liu, J. Y., Roberts, T. J., Burgdorf, K., &
Herrell, J. M. (2003). Children of mothers with serious substance abuse problems: An
accumulation of risks. The American Journal of Drug and Alcohol Abuse, 29(4), 743-
758. doi: 10.1081/ADA-120026258
Conry, J., & Fast, D. (2000). Fetal Alcohol Syndrome and the criminal justice system.
Vancouver, ,British Columbia, Canada: Law Society of British Columbia and British
Columbia FAS Resource Society.
Cook, P., Kellie, R., Jones, K., & Goosen, L. (2000). Tough kids and substance abuse: A drug
awareness program for children and adolescents with ARND, FAS, FAE and cognitive
disabilities. Winnipeg, MB: Addictions Foundation of Manitoba.
FAMILY TREATMENT OF ADHD AND FASD 118
Cordes, S. (2005). Molecular genetics of the early development of hindbrain serotonergic
neurons. Clinical Genetics, 68(6), 487-494. doi: 10.1111/j.1399-0004.2005.00534.x
Davis, E., Barnhill, L. J., & Saeed, D. A. (2008). Treatment models for treating patients with
mental illness and developmental disability. Psychiatric Quarterly, 79(3), 204-223.
doi:1 0.1007/s11126-008-9082-2
DeBeillis, M. D., & VanDillen, T. (2005). Childhood post-traumatic stress disorder: An
overview. Child and Adolescent Psychiatry Clinics of North America, 14(4), 745-772.
doi: 10.1016/j.chc.2005.05.006
Dempsey, I., & Dunst, C. J. (2004). Help-giving styles as a function of parent empowerment in
families with a young child with a disability. Journal of Intellectual and Developmental
Disability, 29(1), 40-51. doi: 10.1080/13668250410001662874
Dempsey, I., & Keen, D. (2008). A review of processes and outcome in family-centered services
for children with a disability. Topics in Early Childhood Special Education, 28(1), 42-
52. doi: 10.1177/0271121408316699
Denckla, M. B. (1994). Measurement of executive function. In G. R. Lyon (Ed.), Frames of
reference for the assessment of learning disabilities: New views on measurement issues
(pp. 117-142). Baltimore, MD: Paul Brookes.
Dery, M., Toupin, J., Pauze, R., & Verlaan, P. (2005). Frequency of mental health disorders in a
sample of elementary school students receiving special educational services for
behavioural difficulties. Canadian Journal of Psychiatry, 49(12), 769-775. Retrieved
from http://ww1.cpa-apc.org/Publications/Archives/CJP/2004/november/dery.asp
Devries, J., & Walder, A. (2004). Fetal alcohol syndrome through the eyes of parents.
Addictions Biology, 9(2), 119-126. doi: 10.1080/13556210410001716971
FAMILY TREATMENT OF ADHD AND FASD 119
DiPietro, J. A., Hodgson, D. M., Costigan, K. A., Hilton, S. C, Johnson, T. R. (1996). Fetal
neurobehavioral development. Child Development, 67(5), 2553-2567. Retrieved from
http://www.jstor.org/pss/1131640
Dishion, T. E., & Kavanaugh, K. (2003). Intervening in adolescent behaviour problems: A
family-centred approach. New York, NY: Guilford Press.
Disney, E. R., Iacono, W., McGue, M., Tully, E., & Legrand, L. (2008). Strengthening the case:
Prenatal alcohol exposure is associated with increased risk for conduct disorder.
Pediatrics, 122(6), e1225-e1230. doi:10.1542/peds.2008-1380
Dodge, K. A. (2006). The problem of deviant peer influences in intervention programs. New
York, NY: Guilford Press.
D’Onofrio, B. M., Van Hulle, C. A., Waldman, I. D., Rodgers, J. L., Rathouz, P. J., & Lahey, B.
B. (2007). Causal influences regarding prenatal alcohol exposure and childhood
externalizing problems. Archives of General Psychiatry, 64(11), 1296-1304. Retrieved
from http://www.cds.unc.edu/CCHD/F2008/10-13/DOnofrio%202007d.pdf
Dopfner, M., Breuer, D., Schurmann, S., Wolf Metternich, T., Raedamacher, C., & Lehmkuhl,
G. (2004). Effectiveness of an adaptive multimodal treatment in children with attention-
deficit hyperactivity disorder global outcome. European Child and Adolescent
Psychiatry, 13(1), 117-129. doi: 10.1007/s00787-004-1011-9
Douglas, V. I. (2005). Cognitive deficits in children with attention deficit hyperactivity disorder:
A long-term follow-up. Canadian Psychology, 46(1), 23-31. doi:1 0.1037/h0085821
Duncan, S. C., Duncan, T. E., & Strycker, L. (2000). Risk and protective factors influencing
alcohol problem behaviour: A multivariate latent growth curve analysis. Annals of
Behavioural Medicine, 22(2), 103-109. doi: 10.1007/BF02895772
FAMILY TREATMENT OF ADHD AND FASD 120
Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., & Johnson,
L. D. (2003). The session rating scale: Preliminary psychometric properties of a
“working” alliance measure. Journal of Brief Therapy, 3(1), 3-12. Retrieved from
http://www.scottdmiller.com/uploadedFiles/documents/SessionRatingScale-JBTv3n1.pdf
Duquette, C., Stodel, E., Fullarton, S., & Hagglund, K. (2006). Persistence in high school:
Experiences of adolescents and young adults with fetal alcohol spectrum disorder.
Journal of Intellectual and Developmental Disability, 31(4), 219-231. doi:
10.1080/13668250601031930
Dunst, C. J. (2002). Family-centred practices: Birth through high school. Journal of Special
Education, 36(3), 139-147. doi: 10.1177/00224669020360030401
Dunst, C. J., Boyd, K., Trivette, C. M., & Hamby, D. W. (2002). Family-oriented program
models and professional helpgiving practices. Family Relations, 51(3), 221-229. doi:
10.1111/j.1741-3729.2002.00221.x
Education Publication Center. (2008). Identifying and treating attention deficit hyperactivity
disorder: A resource for school and home (4th ed). Jessup, MD: ED Publications.
Retrieved from http://www2.ed.gov/rschstat/research/pubs/adhd/adhd-identifying-
2008.pdf
Edwards, J. H. (2002). Evidence-based treatment for child ADHD: ‘Real world’ practice
implications. Journal of Mental Health Counseling, 24(2), 126-140. Retrieved from
http://findarticles.com/p/articles/mi_hb1416/is_2_24/ai_n28919709/
Emerson, E. (2000). Behavior analysis. In C. Gillberg and G. O’Brien (Eds.), Developmental
disabilities and behaviour (pp. 77-88). Suffolk, England: The Lavenham Press Ltd.
FAMILY TREATMENT OF ADHD AND FASD 121
Eriksson, P., Ankarberg, E., & Fredriksson, A. (2000). Exposure to nicotine during a defined
period in neonatal life induces permanent changes in brain nicotinic receptors and in
behaviour of adult mice. Brain Research, 853(1), 41-48. doi: 10.1016/S0006-
8993(99)02231-3
Ernst, M., Zametkin, A. J., Matochik, J. A., Pascualvaca, D., Jons, P. H., & Cohen, R. M. (1999).
High midbrain [18
F]DOPA accumulation in children with attention deficit hyperactivity
disorder. American Journal of Psychiatry, 156(8), 1209-1215. Retrieved from
http://ajp.psychiatryonline.org/cgi/reprint/156/8/1209?ijkey=79b2669ebae0c38b02e4545
10d4c1439817632f0
Estenson, P. (2003, June). The value of psychotherapy for adults with fetal alcohol spectrum
disorder. The Iceberg, 13(2), Retrieved from
http://www.fasiceberg.org/newsletters/Vol13Num2_Jun2003.htm
Evans, S. W., Timmins, B., Sibley, M., White, L. C., Serpell, Z. N., & Schultz, B. (2006).
Developing coordination in multimodal, school-based treatment for young adolescents
with ADHD. Education and Treatment of Children, 29(2), 359-378.
Evans, S. W., Pelham, W. E., Smith, B. H., Bukstein, O., Gnagy, E. M., Greiner, A. R., . . .
Baron-Myak, C. (2001). Dose-response effects of methylphenidate on ecologically valid
measures of academic performance and classroom behaviour in adolescents with ADHD.
Experimental and Clinical Psychopharmacology, 9(2), 163-175. doi: 10.1037//1064-
1297.9.2.163
Eyberg, S. M., Nelson, M. N., & Boggs, S. R. (2008). Evidence-based psychosocial treatments
for children and adolescents with disruptive behavior. Journal of Clinical Child &
Adolescent Psychology, 37(1), 215–237. doi: 10.1080/15374410701820117
FAMILY TREATMENT OF ADHD AND FASD 122
Fabiano, C. A., & Pelham, W. E. (2003). Improving the effectiveness of behavioral classroom
interventions for attention-deficit/hyperactivity disorder: A case study. Journal of
Emotional and Behavioral Disorders, 11(2), 122-128. doi:
10.1177/106342660301100206
Famy, C., Streissguth, A. P., & Unis, A. S. (1998). Mental illness in adults with fetal alcohol
syndrome and fetal alcohol effects. American Journal of Psychiatry, 155(4), 552-554.
Retrieved from http://ajp.psychiatryonline.org/cgi/reprint/155/4/552
Fischer, R. L. (2004). Assessing client change in individual and family counselling. Research
on Social Work Practice, 14(2), 102-111. doi: 10.1177/1049731503257868
Fletcher, T. B., & Hinkle, J. S. (2002). Adventure based counselling: An innovation in
counseling. Journal of Counseling and Development, 80(3), 277-285. Retrieved from
http://www.highbeam.com/doc/1G1-90679561.html
Forness, S. R., & Kavale, K. A. (2001). ADHD and a return to the medical model of special
education. Education and Treatment of Children, 24(3), 224-247. Retrieved from
http://www.highbeam.com/doc/1G1-81529350.html
Foster, S. L., Cunningham, P. B., Warner, S. E., McCoy, D. M., Barr, T. S., & Henggeler, S. W.
(2009). Therapist behaviour as a predictor of black and white caregiver responsiveness in
multisystemic therapy. Journal of Family Psychology, 23(5), 626-635.
doi:10.1037/a0016228
Foxx, R. M. (2003). The treatment of dangerous behaviour. Journal of Behavioural
Interventions, 18(1), 1-21. doi:10.1002/bin.127
FAMILY TREATMENT OF ADHD AND FASD 123
Fryer, S. L., McGee, C. L., Matt, G. E., Riley, E. P., & Mattson, S. N. (2007). Evaluation of
psychopathological conditions in children with heavy prenatal alcohol exposure.
Pediatrics, 119(3), e733-e741. doi: 10.1542/peds.2006-1606
Furman, L. (2002). What is attention-deficit hyperactivity disorder (ADHD)? Journal of Child
Neurology, 20(12), 993-1002. doi: 10.1177/08830738050200121301
Gladstone, J., Levy, M., Nylman, I., & Koren, G. (1997). Characteristics of pregnant women
who engage in binge alcohol consumption. Canadian Medical Association Journal,
156(60), 789-794. Retrieved from http://www.cmaj.ca/cgi/reprint/156/6/789
Giarratano, G., & Williams, A. W. (2007). Gene-environmental influences on fetal alcohol
syndrome: State of the science. International Journal of Nursing in Intellectual and
Developmental Disabilities, 3(2). Retrieved from
http://journal.ddna.org/volumes/volume-3-issue-2/articles/1-gene-environment-
influences-on-fetal-alcohol-syndrome-state-of-the-science
Giedd, J. N., Blumenthal, J., Molloy, E., & Castellanos, F. X. (2001). Brain imaging of attention
deficit/hyperactivity disorder. Annals of the New York Academy of Sciences, 931(1), 33-
49. doi: 10.1111/j.1749-6632.2001.tb05772.x
Gioia, G. A., & Isquith, P. K. (2002). New perspectives on educating children with ADHD:
Contributions of the executive functions. Journal of Health Care Law and Policy,
124(5), 1-26. Retrieved from http://www.caspsurveys.org/NEW/pdfs/ch08_01.pdf
Goldstein, S. (1996). Managing attention and learning disabilities in late adolescence and
adulthood. New York, NY: Wiley.
FAMILY TREATMENT OF ADHD AND FASD 124
Goodlett, C., & Horn, K. (2001). Mechanisms of alcohol induced damage to the nervous system.
Alcohol Research and Health, 25(3), 175-184. Retrieved from
http://pubs.niaaa.nih.gov/publications/arh25-3/175-184.pdf
Glass, S. J., & Myers, J. E. (2001). Combining the old and the new to help adolescents:
Individual psychology and adventure-based counseling. Journal of Mental Health
Counseling, 23(2), 104-114. Retrieved from
https://libres.uncg.edu/ir/uncg/f/J_Myers_Combining_2001.pdf
Green, J. H. (2007). Fetal alcohol spectrum disorders: understanding the effects of prenatal
alcohol exposure and supporting students. Journal of School Health, 77(3), 103-108.
doi: 10.1111/j.1746-1561.2007.00178.x
Greene, R. W., & Ablon, J. S. (2001). What does the MTA study tell us about effective
psychosocial treatment for ADHD? Journal of Clinical Child Psychology, 30(1), 114-
121. Retrieved from
http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?hid=15&sid=93e09fa4-51d9-44af-
9466-cdfdf572fda6%40sessionmgr15&vid=4
Guerri, C., Bazinet, A., & Riley, E. P. (2009). Foetal alcohol spectrum disorders and alterations
in brain and behaviour. Alcohol and Drug Research, 44(2), 108-114. doi:
10.1093/alcalc/agn105
Guralnick, M. J. (1997). Effectiveness of early intervention for vulnerable children: A
developmental perspective. American Journal of Mental Retardations, 102(4), 319-345.
doi: 10.1352/0895-8017(1998)102<0319:EOEIFV>2.0.CO;2
FAMILY TREATMENT OF ADHD AND FASD 125
Hallowell, E. M. (1995). Psychotherapy of adult attention deficit disorder. In K. G. Nadeau
(Ed.), A comprehensive guide to attention deficit disorder in adults: Research, diagnosis,
and treatment (pp. 146-167). New York, NY: Brunner/Mazel.
Hallowell, E. M., & Ratey, J. J. (1994). Driven to distraction. New York, NY: Touchstone.
Hanna, F. J., Hanna, C. A., & Keys, S. G. (1999). Fifty strategies for counseling defiant,
aggressive adolescents: Reaching, accepting, and relating. Journal of Counseling and
Development, 77(4), 395-404. Retrieved from
http://www.milcahferguson.com/MEF/Home_files/50%20Strategies%20Youth.pdf
Harpin, V. A (2005). The effect of ADHD on the life of an individual, their family, and
community from preschool to adult life. Archives of Disease in Childhood, 90(Suppl 1),
i2-i7. doi: 10.1136/adc.2004.059006
Harris, J. C. (2000). Multimodal interventions for developmental neuropsychiatric disorders. In
C. Gillberg and G. O’Brien (Eds.), Developmental disabilities and behaviour (pp. 125-
137). Suffolk, England: Lavenham Press.
Harvard Mental Health. (2008). Treating ADHD in children and adolescents. Harvard Health
Publications, 25(4), 1-3. Retrieved from http://search.ebscohost.com
Harwood, M. D., & Eyberg, S. M. (2004). Therapist verbal behaviour early in treatment:
Relation to successful completion of parent-child interaction therapy. Journal of Clinical
Child and Adolescent Psychiatry, 33(3), 601-612. Retrieved from
http://pcit.phhp.ufl.edu/Literature/HarwoodEyberg2004.pdf
Healthy Child Manitoba (2007). What educators need to know about FASD: Working together to
educate children in Manitoba with fetal alcohol spectrum disorder. Winnipeg, Manitoba,
Canada: Healthy Child Manitoba.
FAMILY TREATMENT OF ADHD AND FASD 126
Henggeler, S. W. (1999). Multisystemic therapy: An overview of clinical procedures, outcomes,
and policy implications. Child Psychology and Psychiatry Review, 4(1), 2-10. doi:
10.1111/1475-3588.00243
Henggeler, S. W., & Lee, T. (2003). Multisystemic treatment of serious clinical problems. In A.
E. Kazdin and J. R. Weisz (Eds.), Evidence based psychotherapies for children and
adolescents (pp. 301-322). New York, NY: Guilford Press.
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B.
(1998). Multisystemic treatment of antisocial behavior in children and adolescents. New
York, NY: Guilford Press.
Henry, J., Sloane, M., & Black-Pond, C. (2007). Neurobiology and neurodevelopmental impact
of childhood traumatic stress and prenatal alcohol exposure. Language, Speech, and
Hearing Services in Schools, 38(2), 99-108. doi: 10.1044/0161-1461
Hesslinger, B., Van Elst, L. T., Nyberg, E., Dykierek, P., Richter, H., Berner, M., . . . Ebert, D.
(2002). Psychotherapy of attention-deficit hyperactivity disorder in adults: A pilot study
using a structured skills training program. European Archives of Psychiatry and Clinical
Neuroscience, 252(4), 177-184. doi: 10.1007/s00406-002-0379-0
Hoyme, H. E., May, P. A., Kalberg, W. O., Kodituwakku, P., Gossage, J. P., Trujillo, P. M., . . .
Robinson, L. K. (2005). A practical clinical approach to diagnosis of fetal alcohol
spectrum disorders: Clarification of the 1996 Institute of Medicine criteria. Pediatrics,
115(1), 39-47. doi: 10.1542/peds.2004-0259
Hoza, B., Gerdes, A. C., Mrug, S., Hinshaw. S. P., Bukowski, W. M., Gold, J. A., . . . Wigal, T.
(2005). Peer-assessed outcomes in the multimodal treatment study of children with
FAMILY TREATMENT OF ADHD AND FASD 127
attention deficit hyperactivity disorder. Journal of Clinical Child and Adolescent
Psychology, 34(1), 74-86. doi: 10.1207/s15374424jccp3401_7
Huey, S. J., Henggeler, S. W., Brondino, M. J., & Pickret, S. G. (2000). Mechanisms of change
in multisystemic therapy: Reducing delinquent behaviour through therapist adherence
and improved family and peer functioning. Journal of Consulting and Clinical
Psychology, 68(3), 451-467. doi: 10.1037/0022-006X.68.3.451
Huggins, J. E., Grant, T., O’Malley, K., & Streissguth, A. P. (2008). Suicide attempts among
adults with fetal alcohol spectrum disorders: Clinical considerations. Mental Health
Aspects of Developmental Disabilities, 11(2), 33-41. Retrieved from
http://findarticles.com/p/articles/mi_6883/is_2_11/ai_n28524972
Hurley, A. D. (2005). Psychotherapy is an essential tool in the treatment of psychiatric
disorders for people with mental retardation. Mental Retardation, 43(6), 445-448. doi:
10.1352/0047-6765
Ingersoll, B. D., & Goldstein, S. (1993). Attention deficit disorder and learning disabilities:
Realities, myths and controversial treatments. New York, NY: Doubleday.
Johnston, C. & Mash, E. J. (2001). Families of children with ADHD: Review and
recommendations for further research. Clinical Child and Family Psychology Review,
4(3), 183-207. doi: 10.1023/A:1017592030434
Jones, K. L., & Smith, D. W. (1973). Recognition of the fetal alcohol syndrome in early infancy.
Lancet, 302(7836), 999-1001. doi: 10.1016/S0140-6736(73)91092-1
Kandel, D. B., & Logan, J. A. (1984). Patterns of drug use from adolescence to young
adulthood: I. Periods of risk for initiation, continued use, and discontinuation. American
FAMILY TREATMENT OF ADHD AND FASD 128
Journal of Public Health, 74(7), 660-666. Retrieved from
http://ajph.aphapublications.org/cgi/reprint/74/7/660
Kazdin, A. E. (1997). Parent management training: Evidence, outcomes, and issues. Journal of
American Academy of Child and Adolescent Psychiatry, 36(10), 1349–1356. Retrieved
from http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?hid=110&sid=93e09fa4-
51d9-44af-9466-cdfdf572fda6%40sessionmgr15&vid=14
Kazdin, A. E., & Whitley, M. K. (2006). Pretreatment social relations, therapeutic alliance, and
improvements in parenting practices in parent management training. Journal of
Consulting and Clinical Psychology, 74(2), 346-355. doi:10.1037/0022-006X.74.2.346
Kelly, S. J., Day, N., & Streissguth, A. P. (2000). Effects of prenatal alcohol exposure on social
behaviour in humans and other species. Neurotoxicology and Teratolgoy, 22(2), 143-
149. doi: 10.1016/S0892-0362(99)00073-2
Kendall, P. C., Reber, M., McLeer, S., Epps, J., & Ronan, K. R. (1990). Cognitive-behavioral
treatment of conduct-disordered children. Journal of Cognitive Therapy and Research,
14(3), 779-797. doi: 10.1007/BF01183997
Kewley, G. (1999). Attention deficit hyperactivity disorder: Recognition, reality and resolution.
London, England: David Fulton.
King, G., King, S., Rosenbaum, P., & Goffin, R. (1999). Family-centered caregiving and well-
being of parents of children with disabilities: Linking process with outcome. Journal of
Pediatric Psychology, 24(1), 41-53. Retrieved from
http://jpepsy.oxfordjournals.org/cgi/reprint/24/1/41.pdf
FAMILY TREATMENT OF ADHD AND FASD 129
Klassen, A. F., Miller, A., & Fine, S. (2004). Health-related quality of life in children and
adolescents who have a diagnosis of attention-deficit/hyperactivity disorder. Pediatrics,
114(5), e541-e547. doi: 10.1542/peds.2004-0844
Knight, B. (2008, January). An approach to psychotherapy for individuals with FASD. The
Iceberg, 17(4). Retrieved from
http://www.fasiceberg.org/newsletters/Vol17Num4_Jan2008.htm
Krueger, M., & Kendall, J. (2001). Descriptions of self: An exploratory study of adolescents
with ADHD. Child and Adolescent Psychiatry, 14(2), 61-72. doi: 10.1111/j.1744-
6171.2001.tb00294.x
Kodituwakku, P. W. (2007). Defining the behavioral phenotype in children with fetal alcohol
spectrum disorders: A review. Neuroscience and Biobehavioral Reviews, 31(2), 192-201.
doi: 10.1016/j.neubiorev.2006.06.020
Kovacs, M., & Devlin, B. (1998). Internalizing disorders in childhood. Child Psychology and
Psychiatry and Allied Disciplines, 39(1), 47-64. doi: 10.1017/S0021963097001765
Lach, L.M., Kohen, D.E., Garner, R.E., Brehaut, J.C., Miller, A.R., Klassen, A.F., &
Rosenbaum, P.L. (2009). The health and psychosocial functioning of caregivers of
children with neurodevelopmental disorders. Disability and Rehabilitation, 31(9), 607-
618. Doi 10.1080/08916930802354948
Landau, S., & Moore, L. A. (1991). Social skill deficits in children with attention-deficit
hyperactivity disorder. School Psychology Review, 202(2), 235-251. Retrieved from
http://search.ebscohost.com
FAMILY TREATMENT OF ADHD AND FASD 130
Landgren, M., Svensson, L., Stromland, K., & Gronlund, M. A. (2010). Prenatal alcohol
exposure and neurodevelopmental disorders in children adopted from Eastern Europe.
Pediatrics, 125(5), e1178-e1185. doi:10.1542/peds.2009-0712
Lee, K. T., Mattson, S. N., & Riley, E. P. (2004). Classifying children with heavy prenatal
alcohol exposure using measures of attention. International Neuropsychological Society,
10(2), 271-277. doi: 10.1017/S1355617704102142
Leech, S. L., Larkby, C. A., Day, R., & Day, N. L. (2006). Predictors and correlates of high
levels of depression and anxiety symptoms among children at age 10. Child and
Adolescent Psychiatry, 45(2), 223-230. doi: 10.1097/01.chi.0000184930.18552.4d
Le Fever, G. B., Villers, M. S., & Morrow, A. L. (2002). Parental perceptions of adverse
educational outcomes among children diagnosed and treated for ADHD: A call for
improved school/provider collaboration. Psychology in the Schools, 39(1), 63-71. doi:
10.1002/pits.20099
Lemola, S., Stadlmayr, W., & Crob, A. (2009). Infant irritability: The impact of fetal alcohol
exposure, maternal depressive symptoms, and low emotional support from the husband.
Infant Mental Health, 30(1), 57-81. doi:10.1002/imhj.20203
Lennox, N., Taylor, M., Rey-Conde, T., Bain, C., Boyle, F. M., & Purdie, D. M. (2004). Ask for
it: Development of a health advocacy intervention for adults with intellectual disability
and their general practitioners. Heath Promotion International, 19(2), 167-175.
Retrieved from http://heapro.oxfordjournals.org/cgi/content/full/19/2/167
Levine, M. D. (1995). Childhood neurodevelopmental dysfunction and learning disorders.
Harvard Health Publications, 12(1), 1-3. Retrieved from http://search.ebscohost.com
FAMILY TREATMENT OF ADHD AND FASD 131
Liptak, G., Orlando, M., Yingling, J., Theurer-Kaufman, D., Malay, D., Tompkins, L., & Flynn,
J. (2006). Satisfaction with primary health care received by families of children with
developmental disabilities. Pediatric Health Care, 20(4), 245-252. doi:
10.1016/j.pedhc.2005.12.008
Linnet, K. M., Dalsgaard, S., Obel, C., Wisborg, K., Henriksen, T. B., Rodriguez, A., , . . .
Jarvelin, M. (2003). Maternal lifestyle factors in pregnancy risk of attention deficit
hyperactivity disorder and associated behaviors: Review of the current evidence.
American Journal of Psychiatry, 160(6), 1028-1040. Retrieved from
http://ajp.psychiatryonline.org/cgi/reprint/160/6/1028
Lockhart, P. J. (2001). Fetal alcohol spectrum disorder for mental health professionals. Current
Opinions in Psychiatry, 14(5), 263-269. Retrieved from http://journals.lww.com/co-
psychiatry/Abstract/2001/09000/Fetal_alcohol_spectrum_disorders_for_mental_health.7.
aspx
Lochman, J. E., Barry, T. D., & Pardini, P. A. (2003). Anger control training for aggressive
youth. In A. E. Kazdin and J. R. Weisz (Eds.), Evidence based psychotherapies for
children and adolescents (pp. 263-281). New York, NY: Guilford Press.
Madsen, W. C. (2009). Collaborative helping: A practice framework for family process.
Family-Centered Services, 48(1), 103-116. doi: 10.1111/j.1545-5300.2009.01270.x
Maier, S. E., Strittmatter, M. A., Chen, W. A., & West, J. R. (1995). Changes in blood alcohol
levels as a function of alcohol consumption and repeated alcohol exposure in adult
female rats: Potential risk factors for alcohol-induced fetal brain injury. Alcoholism:
Clinical and Experimental Research, 19(4), 923-927. doi: 10.1111/j.1530-
0277.1995.tb00968.x
FAMILY TREATMENT OF ADHD AND FASD 132
Malbin, D. V. (2008). Fetal alcohol spectrum disorders: A collection of information for parents
and professionals (2nd ed.). Portland, OR: FASCETS.
Mate, G. (1999). Scattered: How attention deficit disorder attention deficit (hyperactivity)
disorder originates and what you can do about it. New York, NY: Plume.
Mattheis, P. (2007). FASD and ADHD: The nuts and bolts of diagnosis and treatment in the real
world. In K.D. O’Malley (Ed.), ADHD and Fetal Alcohol Spectrum Disorders (pp. 179-
198). New York, NY: Nova Science.
Mattson, S. N., Calarco, K. E., & Lang, A. R. (2006). Focused and shifting attention in children
with heavy prenatal alcohol exposure. Neuropsychology, 20(3), 361-369. doi:
10.1111/j.1545-5300.2009.01270.x
McGee, C. L., Fryer, S. L., Bjorkquist, O. A., Mattson, S. N., & Riley, E. P. (2008). Deficits in
social problem solving in adolescents with prenatal alcohol exposure. American Journal
of Drug and Alcohol Abuse, 34(4), 423-431. doi:10.1080/00952990802122630
McMahon, R., & Forehand, R. (2003). Helping the noncompliant child (2nd ed.). New York,
NY: Guilford Press.
Mela, M. (2006). Accommodating the fetal alcohol spectrum disorders in the Diagnostic and
Statistical Manual of Mental Disorders (DSM V). Journal of FAS International, 4(e23),
1-10. Retrieved from http://www.motherisk.org/FAR/index.jsp
Merikanayas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., . . . Swendsen,
J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results from the
National Comorbidity Study – Adolescent Supplement (NCS-A). Journal of the
American Academy of Child and Adolescent Psychiatry, 49(10), 980-989. doi:
10.1016/j.jaac.2010.05.017
FAMILY TREATMENT OF ADHD AND FASD 133
Merkel, L. (n.d.). ADHD in adults. Retrieved from
http://healthsystem.virginia.edu/internet/psych-training/seminars/adult%20adhd.pdf
Mick, E., Biederman, J., Faraone, S. V., Sayer, J., & Kleinman, S. (2002). Case-control study of
attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use
during pregnancy. Child & Adolescent Psychiatry, 41(4), 378-385. doi:
10.1097/00004583-200204000-00009
Mills, R. M. T., McLennan, J. D., & Caza, M. M. (2006). Mental health and other service use by
young children with fetal alcohol spectrum disorder. Journal of FAS International, 4(e1),
1-11. Retrieved from http://www.motherisk.org/JFAS_documents/JFAS_5010_e1.pdf
Miranda, A., Jarque, S., & Tarraga, R. (2006). Interventions in school setting for students with
ADHD. Exceptionality, 14(1), 35-52. doi: 10.1207/s15327035ex1401_4
Moore, T. E., & Green, M. (2004). Fetal alcohol spectrum disorder and the criminal justice
system. Criminal Reports, 19(1), 99-108. Retrieved from
http://depts.washington.edu/fadu/legalissues/FASDCrimRep.pdf
Morrissette, P. J. (2001). Fetal alcohol syndrome: Parental experiences and the role of family
counselors. The Qualitative Report, 6(2), 1-19. Retrieved from
http://www.nova.edu/ssss/QR/QR6-2/morrissette.html
Murphy, K. (2005). Psychosocial treatments for ADHD in teens and adults: A practice-friendly
review. Journal of Clinical Psychology, 61(5), 607-619. Retrieved from http://www.
onlinelibrary.wiley.com
Stratton, K., Howe, C., & Battaglia, F. (1996). Fetal alcohol syndrome: Diagnosis,
epidemiology, prevention and treatment. National Institute of Medicine [IOM].
Washington, DC: National Academy Press.
FAMILY TREATMENT OF ADHD AND FASD 134
North Carolina Division of Social Services. (2004). Family-centered practice with cognitive
limitations. Children’s Services Practice Notes, 9(2). Retrieved from
http://www.practicenotes.org/vol9_no2/fcp.htm
Novick, N. J., & Streissguth, A. P. (1995, Fall). Thoughts on treatment of adults and adolescents
impaired by fetal alcohol exposure. Treatment Today, 7(3), 14. Retrieved from
http://depts.washington.edu/fadu/FAS_FAE2.html
O’Connor, M. J. (2001). Prenatal alcohol exposure and infant negative affect as precursors of
depressive features in children. Infant Mental Health, 22(3), 291-299. doi:
10.1002/imhj.1002
O’Connor, M. J., & Kasari, C. (2000). Prenatal alcohol exposure and depressive features in
children. Alcoholism: Clinical and Experimental Research, 24(7), 1084–1092. doi:
10.1111/j.1530-0277.2000.tb04654.x
O’Connor, M. J., & Paley, B. (2006). The relationship of prenatal alcohol exposure and the
postnatal environment to child depressive symptoms. Pediatric Psychology, 31(1), 50-
64. doi: 10.1093/jpepsy/jsj021
O’Connor, M. J., & Paley, B. (2009). Psychiatric conditions associated with prenatal alcohol
exposure. Developmental Disabilities Research Reviews, 15(3), 225-234. doi:
10.1002/ddrr.74
O’Connor, M. J., Kogan, N., & Findlay, R. (2002). Prenatal alcohol exposure and attachment
behavior in children. Alcoholism: Clinical and Experimental Research, 26(10), 1592-
1602. doi: 10.1111/j.1530-0277.2002.tb02460.x
O’Connor, M. J., McCracken, J., & Best, A. (2006). Under recognition of prenatal alcohol
exposure in a child inpatient psychiatric setting. Mental Health Aspects of
FAMILY TREATMENT OF ADHD AND FASD 135
Developmental Disabilities, 9(4), 105-108. Retrieved from
http://tarjancenter.ucla.edu/upload/Under%20Recognition%20of%20Prenatal%20Alcoho
l%20Exposure.pdf
O’Connor, M. J., Sigman, M., & Brill, N. (1987). Disorganization of attachment in relation to
maternal alcohol consumption. Consulting and Clinical Psychology, 55(6), 831-836.
doi: 10.1037/0022-006X.55.6.831
O’Connor, M. J., Sigman, M., & Kasari, C. (1992). Attachment behavior of infants exposed to
alcohol prenatally: Mediating effects of infant affect and mother–infant interaction.
Development and Psychopathology, 4(2), 243–256. doi: 10.1017/S0954579400000122
O’Connor, M. J., Shah, B., Whaley, S., Cronin, P., Gunderson, B., & Graham, J. (2002).
Psychiatric illness in a clinical sample of children with prenatal alcohol exposure.
American Journal of Drug and Alcohol Abuse, 28(4), 743-754. doi: 10.1081/ADA-
120015880
O’Connor, M. J., Frankel, F., Paley, B., Schonfeld, A.M., Carpenter, E., Laugeson, E. A., &
Marquardt, R., (2006). A controlled social skills training for children with fetal alcohol
spectrum disorders. Consulting and Clinical Psychology, 74(4), 639-648. doi:
10.1037/0022-006X.74.4.639
Okie, S. (2006). ADHD in adults. New England Journal of Medicine, 354(25), 2637-2641.
Retrieved from http://logocom.be/technisch/medisch/rilatine/pdf/060622-New-England-
Journal-ADHD-in-adults.pdf
Olson, H. C., O’Connor, M. J., & Fitzgerald, H. E. (2001). Lessons learned from the
developmental impact of prenatal alcohol use. Infant Mental Health Journal, 22(3), 271-
290. doi: 10.1002/imhj.1001
FAMILY TREATMENT OF ADHD AND FASD 136
Olson, H.C., Jirikowic, T., Kartin, D., & Astley, S. (2007). Responding to the challenge of early
intervention for fetal alcohol spectrum disorders. Infants and Young children, 20(2), 172-
189. doi: 10.1097/01.IYC.0000264484.73688.4a
O’Malley, K. (2007). Multi-modal management strategies through the lifespan. In K.D.
O’Malley (Ed.), ADHD and Fetal Alcohol Spectrum Disorders (pp. 199-213). New York,
NY: Nova Science.
O’Malley, K. D., & Nanson, J. (2007). Clinical implications of a link between fetal alcohol
spectrum disorder and attention deficit hyperactivity disorder. Canadian Journal of
Psychiatry, 47(4), 349-354. Retrieved from http://ww1.cpa-
apc.org/publications/archives/cjp/2002/may/omalley.PDF
O’Malley, K. D., & Streissguth, A. (2003). Clinical intervention and support for children aged
zero to five years with fetal alcohol spectrum disorder and their parents/caregivers.
Retrieved from http://excellence-
jeunesefants.ca/documents/Omalley_StreissguthANGxp.pdf
Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2003). Fifty years of process-outcome
research: Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield’s
handbook of psychotherapy and behavior change (5th ed., pp. 307-390). New York. NY:
Wiley.
Ory, N. & Dykstra, T. (2007). Working with people with challenging behaviours: A guide for
maintaining positive relationships. New Lenox, IL: High Tide Press.
Paley, B., & O’Connor, M. J. (2009). Intervention for individuals with fetal alcohol spectrum
disorders: Treatment approaches and case management. Developmental Disabilities
Research Reviews, 15(1), 258-267. doi: 10.1002/ddrr.67
FAMILY TREATMENT OF ADHD AND FASD 137
Paley, B., O’Connor, M. J., Frankel, F., & Marquardt, R. (2006). Predictors of stress in parents
of children with fetal alcohol spectrum disorders. Developmental and Behavioral
Pediatrics, 27(5), 396-404. Retrieved from
http://tarjancenter.ucla.edu/upload/Predictors%20of%20strees%20in%20parents%20of%
20children%20with%20FASD.pdf
Pascoe, J. M., Kokotailo, P. K., & Broekhuizen, F. F. (1995). Correlates of multigravida
women’s binge drinking during pregnancy: A longitudinal study. Archives of Pediatrics
and Adolescent Medicine, 149(12), 1325-1329. Retrieved from http://archpedi.ama-
assn.org/cgi/content/refs/149/12/1325
Pelham, W. E., & Gnagy, E. M. (1999). Psychosocial and combined treatments for ADHD.
Mental Retardation and Developmental Disabilities, 5(3), 225-236. doi:
10.1002/(SICI)1098-2779(1999)5:3<225::AID-MRDD9>3.0.CO;2-E
Perry, B. D. (1999). Memories of states: How the brain stores and retrieves traumatic
experience. In J. Goodwin and R. Attias (Eds.), Splintered reflections: Images of the body
in trauma (pp. 9-38). New York, NY: Basic Books.
Perry. B. D. (2002). Neurodevelopmental impact of violence in childhood. In P. Schetky and E.
Benedek (Eds.), Child and adolescent forensic psychiatry (pp. 221-238). Washington,
DC: American Psychiatric Publishing.
Perry, B. D. (2006). Applying principles of neurodevelopment to clinical work with maltreated
and traumatized children: The Neurosequential model of therapeutics. In N. Boyd Webb
(Ed.), Working with traumatized youth in child welfare (pp. 27-52). New York: Guilford
Press.
FAMILY TREATMENT OF ADHD AND FASD 138
Pomerleau, C. S. (1997). Co-factors for smoking and evolving psychobiology. Addiction, 92(4),
397-408. doi: 10.1080/09652149737962
Premji, S., Benzies, K., Serrell, K., & Hayden, K. A. (2004). Research-based interventions for
children and youth with a fetal alcohol spectrum disorder: Revealing the gap. Child:
Care, Health and Development, 33(4), 389-397. doi: 10.1111/j.1365-2214.2006.00692.x
Pringle-Nelson, C., & Perry, G. P. (2006, November). The Ferris wheel understanding of FASD;
compassion, flexibility are important elements in treating young clients affected by
prenatal alcohol exposure. Addiction Professional, 11(1). Retrieved from
http://www.highbeam.com/doc/1G1-155873252.html
Putnam, F. W. (2006). The impact of trauma on child development. Juvenile and Family Court
Journal, 57(1), 1-11. Retrieved from
http://www.nctsnet.org/nctsn_assets/pdfs/edu_materials/Winter%2006_Putnam.pdf
Rasmussen, C. (2005). Executive functioning and working memory in fetal alcohol spectrum
disorder. Alcoholism: Clinical and Experimental Research, 29(8), 1359-1367. doi:
10.1097/01.alc.0000175040.91007.d0
Rasmussen, C., Horne, K., & Witol, A. (2006). Neurobehavioral functioning in children with
fetal alcohol spectrum disorder. Child Neuropsychology, 12(6), 453-468. doi:
10.1080/09297040600646854
Rathburn, A. (1996). Fetal alcohol syndrome (FAS) and alcohol related neurodevelopmental
disorder (ARND): Considerations for chemical dependency treatment counselors.
Portland, OR: State of Alaska Division of Alcohol and Drug Abuse.
FAMILY TREATMENT OF ADHD AND FASD 139
Riley, E. P., & McGee, C. L (2005). Fetal alcohol spectrum disorders: An overview with
emphasis on changes in brain and behaviour. Experimental Biological Medicine, 230,
357-365. Retrieved from http://ebm.rsmjournals.com/cgi/reprint/230/6/357
Riley, E. P., McGee, C. L., & Sowell, E. R. (2004). Teratogenic effects of alcohol: A decade of
brain imaging. American Journal of Medical Genetics Part C: Seminars in Medical
Genetics, 127c(1), 35-41. doi:1 0.1002/ajmg.c.30014
Robin, A. L. (1998). ADHD in adolescents: Diagnosis and treatment. New York, NY: Guilford
Press.
Roebuck, S. N., Mattson, S. N., & Riley, E. P. (1999). Behavioral and psychosocial profiles of
alcohol-exposed children. Alcoholism: Clinical and Experimental Research, 23(6),
1070-1076. doi: 10.1111/j.1530-0277.1999.tb04227.x
Rowland, A. S., Umbach, D. M., Stallone, L., Naftel, A. J., Bohlig, E. M., & Sandler, D. P.
(2002). Prevalence of medication treatment for attention deficit-hyperactivity disorder
among elementary school children in Johnston County, North Carolina. American
Journal of Public Health, 92(2), 231-234. Retrieved from
http://ajph.aphapublications.org/cgi/reprint/92/2/231?ijkey=65861c4241dc9d3edf8d494c
e230b9b2555bb22c
Rutman, D., La Berge, C., & Wheway, D. (2002). Adults living with FAS/E: Experiences and
support issues in British Columbia. Surrey, British Columbia, Canada: FAS/E Support
Network of British Columbia
Sadock, B. J., & Sadock, V. A. (2007). Kaplan & Sadock’s Synopsis of psychiatry: Behavioral
sciences/clinical psychiatry(10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
FAMILY TREATMENT OF ADHD AND FASD 140
Sampson, P. D. Streissguth, A. P., Bookstein, F. L., Little, R. E., Clarren, S. K., Dehaene, P., . . .
Graham, J. M. (1997). Incidence of fetal alcohol syndrome and prevalence of alcohol-
related neurodevelopmental disorder. Teratology, 56(5), 317-326. doi:
10.1002/(SICI)1096-9926(199711)56:5<317::AID-TERA5>3.0.CO;2-U
Sandvik, E., Diener, E., & Seidlitz, L. (2009). Subjective well-being: The convergence of
stability of self-report and non-self-report measures. Social Indicators Research Series,
39(1), 119-138. doi: 10.1007/978-90-481-2354-4_6
Sayal, K., Heron, J., Golding, J., & Emond, A. (2007). Prenatal alcohol exposure and gender
differences in childhood mental health problems: A longitudinal population-based study.
Pediatrics, 119(2), e426-e434. doi: 10.1542/peds.2006-1840
Schachar, R. K., Chen, S., Logan, G. D., Ornstein, T. J., Crosbie, J., Ickowicz, A., & Pakulak, A.
(2004). Evidence for an error monitoring deficit in attention deficit hyperactivity
disorder. Journal of Abnormal Child Psychology, 32(3), 285-293. doi:
10.1023/B:JACP.0000026142.11217.f2
Schwartz, C., Garland, O., Harrison, E., & Waddell, C. (2006). Treating concurrent substance
use and mental disorders in children and youth: A research report prepared for child and
youth mental health policy branch. Vancouver, British Columbia, Canada: British
Columbia Ministry of Children and Family Development, 2(4), 1-24. Retrieved from
http://www.childhealthpolicy.sfu.ca/research_reports_08/rr_pdf/RR-16-07-full-report.pdf
Selekman, M. D. (2010). Collaborative brief treatment with children. New York, NY: Guilford
Press.
FAMILY TREATMENT OF ADHD AND FASD 141
Semrud-Clikeman, M., & Ellison, P. A. T., (2009). Neuropsychological intervention and
treatment approaches for childhood and adolescent disorders. Child Neuropsychology,
Part IV, 413-433. doi: 10.1007/978-0-387-88963-4_16
Shanley, J. R., & Niec, L. N. (2010). Coaching parents to change: The impact of in vivo
feedback on parents’ acquisition of skills. Journal of Clinical Child and Adolescent
Psychiatry, 39(2), 282-287. doi: 10.1080/15374410903532627
Smith, T., Eikeseth, S., Klevstrand, M., & Lovaas, O. I. (1997). Intensive behavioral treatment
for preschoolers with severe mental retardation and pervasive developmental disorder.
American Journal of Mental Retardation, 102(3), 238–249. doi: 10.1352/0895-8017
Sobotka, T. J. (1989). Neurobehavioral effects of prenatal caffeine. Annals of the New York
Academy of Sciences, 562(1), 327-339. doi: 10.1111/j.1749-6632.1989.tb21030.x
Spadoni, A. D., McGee, C. L., Fryer, S. L., & Riley, E. P. (2007). Neuroimaging and fetal
alcohol spectrum disorder. Neuroscience and Biobehavioral Reviews, 31(2), 239-245.
doi: 10.1016/j.neubiorev.2006.09.006
Spalletta, G., Pasini, A., Pau, F., Guido, G., Menghini, L., & Caltagirone, C. (2001). Prefrontal
blood flow dysregulation in drug naive ADHD children without structural abnormalities.
Journal of Neural Transmission, 108(10), 1203-1216. doi: 10.1007/s007020170010
Spohr, H. L., Willms, J., & Steinhausen, J. C. (2007). Fetal alcohol spectrum disorders in young
adulthood. Pediatrics, 150(2), 175-179:e1. doi: 10.1016/j.jpeds.2006.11.044
Steinhausen, J. C., Willms, J., Winkler Metzke, C., & Spohr, H. L. (2003). Behavioural
phenotype in foetal alcohol syndrome and foetal alcohol effects. Developmental
Medicine and Child Neurology, 45, 178-182. doi: 10.1017/S0012162203000343
FAMILY TREATMENT OF ADHD AND FASD 142
Steinhausen, J. C., & Spohr, H. L. (1998). Long-term outcome of children with fetal alcohol
syndrome: Psychopathology, behavior, and intelligence. Alcoholism: Clinical and
Experimental Research, 22(2), 334-338. doi: 10.1111/j.1530-0277.1998.tb03657.x
Steinhausen, J. C., Willms, J., & Spohr, H. L. (1993). Long-term psychopathology and cognitive
outcomes of children with fetal alcohol syndrome. Child and Adolescent Psychiatry,
32(5), 990-994. doi: 10.1097/00004583-199309000-00016
Stoddart, K. P. (1999). Adolescents with Asperger syndrome: Three case studies of individual
and family therapy. Autism, 3(3), 255-271. doi: 10.1177/1362361399003003004
Streissguth, A. P. (2001). Fetal alcohol syndrome: A guide for families and communities. (2nd
ed.). Baltimore, MD: Paul H. Brooks.
Streissguth, A. P., & O’Malley, K. D. (2000). Neuropsychiatric implications and long-term
consequences of fetal alcohol spectrum disorder. Seminars in Clinical Neuropsychiatry,
5(3), 177-190. Retrieved from http://search.ebscohost.com
Streissguth, A. P., Sampson, P. D., & Barr, H. M. (1989). Neurobehavioral dose-response
effects of prenatal alcohol exposure in humans from infancy to adulthood. Annals of the
New York Academy of Sciences, 562(1), 145-158. doi: 10.1111/j.1749-
6632.1989.tb21013.x
Streissguth, A. P., Barr, H. M., Kogan, J. A., & Bookstein, F. L. (1996). Understanding the
occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and
fetal alcohol effects (FAE). Seattle, WA: University of Washington.
Streissguth, A. P., Bookstein, F. L., Barr, H. M., Press, S., & Sampson, P. D. (1998). A fetal
alcohol behaviour scale. Alcohol Clinical and Experimental Research, 22(2), 325-333.
doi: 10.1111/j.1530-0277.1998.tb03656.x
FAMILY TREATMENT OF ADHD AND FASD 143
Streissguth, A. P., Bookstein, F. L., Barr, H. M., Sampson, P. D., O’ Malley, K. D., & Kogan-
Young, J. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and
fetal alcohol effects. Journal of Developmental and Behavioural Pediatrics, 25(4), 228-
238. Retrieved from
http://www.wisspd.org/html/training/ProgMaterials/Conf2007/WEth/RFALO.pdf
Teicher, M. H., Andersen, S. L., Polcan, A., Anderson, C. M., Navalta, C. P., & Kim, D. M.
(2003). The neurobiological consequences of early stress and childhood maltreatment.
Neuroscience and Biobehavioral Reviews, 27(1-2), 33-44. doi: 10.1016/S0149-
7634(03)00007-1
Thomas, J. D., Sather, T. M., & Whinery, L. A. (2008). Voluntary exercise influences
behavioral development in rats exposed to alcohol during the neonatal brain growth spurt.
Behavioral Neuroscience, 122(6), 1264-1273. doi: 10.1037/a0013271
Tsai, J., & Floyd, R. J. (2004). Alcohol consumption among women who are pregnant or might
become pregnant – United States, 2002. Morbidity and Mortality Weekly Report, 53(50),
1178-1181. Retrieved from http://search.ebscohost.com
Tymchuk, A. J. (1990). Parents with mental retardation. Journal of Disability Policy Studies,
1(4), 43-44. doi: 10.1177/104420739000100403
Van der Kolk, B., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of
extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of
Traumatic Stress, 18(5), 389-399. doi: 10.1002/jts.20047
Van der Oord, S., Prins. P. J. M., Oosterlaan, J., & Emmelkamp, P. M. G. (2007). Does brief,
clinically based, intensive multimodal behaviour therapy enhance the effects of
FAMILY TREATMENT OF ADHD AND FASD 144
methylphenidate in children with ADHD? European Child and Adolescent Psychiatry,
16(1), 48-57. doi: 10.1007/s00787-006-0574-z
Van Schie, P. E. M., Siebes, R. C., Ketelaar, M., & Vermeer, A. (2004). The measure of
processes of care (MPOC): Validation of the Dutch translation. Child Care, Health, &
Development, 30(5), 529-539. Retrieved from
http://www.fss.uu.nl/mpoc/publicaties/cch_451.pdf
Vargas, C. M., & Prelock, P. A. (2004). Caring for children with neurodevelopmental
disabilities and their families: An innovative approach to interdisciplinary practice.
Mahwah, NJ: Erlbaum.
Vig, S., & Kaminer, S. (2002). Maltreatment and developmental disabilities in children.
Journal of Developmental and Physical Disabilities, 14(4), 371-386. doi:
10.1023/A:1020334903216
Vorgraft, Y., Farbstein, I., Spiegel, R., & Apter, A. (2007). Retrospective evaluation of an
intensive method of treatment for children with pervasive developmental disorder.
Autism: The International Journal of Research and Practice 11(5), 413–424. doi:
10.1177/1362361307079605
Walthall, J. C., O’Connor, M. J., & Paley, B. (2008). A comparison of psychopathology in
children with and without prenatal alcohol exposure. Mental Health Aspects of
Developmental Disabilities, 11(3), 69-78. Retrieved from
http://tarjancenter.ucla.edu/upload/A%20comparison%20of%20psychopathology%20IN
%20children.pdf
Weinberg, J., Silwowska, J. H., & Hellemans, K. G. C. (2008). Prenatal alcohol exposure:
Foetal programming, the hypothalamic-pituitary-adrenal axis and sex differences in
FAMILY TREATMENT OF ADHD AND FASD 145
outcome. Journal of Neuroendicronology, 20(4), 470-488. doi: 10.1111/j.1365-
2826.2008.01669.x
Weiss, G., & Hechtman, L. (1993). Hyperactive children group: ADHD in children, adolescents
and adults. New York, NY: Guilford Press.
Whalen, C. K., Jamner, L. D., Henker, B., Delfino, R. J., & Lozano, J. M. (2002). The ADHD
spectrum and everyday life: Experience sampling of adolescent moods, activities,
smoking, and drinking. Child Development, 73(1), 209-227. doi: 10.1111/1467-
8624.00401
Wiggins, D., Singh, K., Getz, H. G., & Hutchins, D. E. (1999). Effects of brief group
intervention for adults with attention deficit/hyperactivity disorder. Journal of Mental
Health Counselling, 21(1), 82-92. Retrieved from http://psycnet.apa.org/psycinfo/1999-
10088-004
Ylvisaker, M., & Feeney, T. J. (1998). Collaborative brain injury intervention: Positive
everyday routines. San Diego, CA: Singular Publishing Group.
Zevenbergen, A. A., & Ferarro, F. R. (2001). Assessment and treatment of fetal alcohol
syndrome in children and adolescents. Journal of Developmental and Physical
Disabilities, 13(2), 123-136. doi: 10.1023/A:1016657107549
Zhou, F. C., Sari, Y., Goodlett, C. R., & Li, T. K. (2001). Prenatal alcohol exposure retards the
migration and development of serotonin neurons in fetal C57BL mice. Developmental
Brain Research, 126(2), 147-155. doi: 10.1016/S0165-3806(00)00144-9
FAMILY TREATMENT OF ADHD AND FASD 146
Appendix A: Diagnostic Criteria for ADHD
A. Either 1 or 2
1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
Inattention
a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b) Often has difficulty sustaining attention in tasks or play activities
c) Often does not seem to listen when spoken to directly
d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not
due to oppositional behavior or failure to understand instructions)
e) Often has difficulty organizing tasks and activities
f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or
homework)
g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h) Is often easily distracted by extraneous stimuli
i) Is often forgetful in daily activities
2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree
that is maladaptive and inconsistent with developmental level:
Hyperactivity
a) Often fidgets with hands or feet or squirms in seat
b) Often leaves seat in classroom or in other situations in which remaining seated is expected
c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be
limited to subjective feelings of restlessness)
d) Often has difficulty playing or engaging in leisure activities quietly
FAMILY TREATMENT OF ADHD AND FASD 147
e) Is often "on the go" or often acts as if "driven by a motor"
f) Often talks excessively
Impulsivity
g) Often blurts out answers before questions have been completed
h) Often has difficulty awaiting turn
i) Often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before 7 years of age.
C. Some impairment from the symptoms is present in 2 or more settings (eg, at school [or work] or at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other
psychotic disorder and are not better accounted for by another mental disorder (eg, mood disorder, anxiety disorder,
dissociative disorder, or personality disorder).
FAMILY TREATMENT OF ADHD AND FASD 148
Appendix B: Counselling Sessions Rating Scale