SAMSHA: “Healthy Baby, Healthy Life” FASD Webinar
This webinar was comprised of 3 small presentations covering a range of FASD-related topics.
FASD PREVENTION AND INTERVENTION
Presentation by: David J. Garry, DO, FACOG
Answering the question of what is important in pre-natal care in order to have a healthy baby,
David identifies the following as critical:
- Establishing when the baby is due in order to ascertain important times for intervention
- Establishing maternal history
- Giving a thorough physical exam and screening for genetic disorders, including information on nutrition and healthy weight gains and on breastfeeding.
- Screening for psychosocial issues including home environment and domestic issues
- Screening for substance use for alcohol, tobacco and other drugs
When asked what are common difficulties for women accessing adequate pre-natal care, he lists the following challenges that have been commonly identified:
- Location, particularly remote areas, where it may be challenging to find an obstetric specialist
- In the US, lack of access to insurance coverage is a significant potential barrier
- Social issues such as prior experience of miscarriage or stillbirth, which may make a woman hesitant to acknowledge her current pregnancy, along with mistrust of “the system”
- Personal issues such as addictions or domestic violence
On the subject of what are issues around establishing routine screening for alcohol use amongst health care professionals, David identifies the primary issues as being provider inconsistency and denial:
- “The women in my practice don’t drink!” There is statistical evidence to clearly demonstrate that not to be a true statement in any demographic.
- Misunderstanding of alcohol risks. Many physicians are still telling women, “1 or 2 drinks are okay”.
- Lack of clarity about what constitutes risky drinking
- Avoiding getting a positive answer to screening questions through body language, tone or phrasing when presenting the screening questions (e.g. “You don’t drink, do you?”)
He stresses that it is helpful to train office staff in medical centres on the risks of alcohol consumption during pregnancy, as patients often talk more openly to staff than to doctors in the more relaxed atmosphere of the waiting room, and advises that increasing awareness of the interventions and supports available after positive testing, e.g. through SAMSHA, ACOG or NIAAA, are likely to increase confidence in dealing with clients who screen positive for alcohol.
David notes that many women are able to choose to eliminate alcohol during pregnancy. One major influence is whether or not she has support within her family, friends and community for making and maintaining that decision. Prevention of FASD is a shared challenge for the community.
EVIDENCE-BASED PRACTICES FOR PREVENTION
Presentation by: Leah Davies, LMSW
When asked about who is at risk of giving birth to a child with an FASD, Leah stresses that all women of childbearing age who drink alcohol are at risk of having an alcohol-exposed pregnancy. Particular risks include:
- Women with co-occurring disorders
- Families with a history of multi-generational alcohol use
- Women who have experienced stressors that increase the risk of alcohol use or abuse
- Women who have an FASD themselves
- Women who have given birth to a child with an FASD
She adds that the most effect way to change the factors that contribute to the problem is by removing or reducing risk factors and enhancing protective factors
Commenting that all women of child-bearing age deserve to have information about the dangers of drinking during pregnancy, she notes that women are most likely to acknowledge alcohol use during pregnancy when asked in a non-judgmental way by someone they trust. She adds that women who need help to stop drinking deserve compassionate, respectful treatment, not blaming or shaming, and suggests that health care professionals can also assist a client to talk with her partner about the risk factors and preventive steps that can be taken to support a healthy pregnancy.
Leah recommends using a diagnostic tool for Screening for Risky Drinking that includes Screening, Brief Intervention, and Referral to Treatment (SBIRT). She gives an example of one of these, the CHOICES program which is based on motivational interviewing. CHOICES is included in SAMSHA and NREPP. It is important to remember that this may be the first time women have had an opportunity to discuss their drinking with a health professional. Find a range of downloadable posters and fact sheets here, along with the CHOICES Curriculum of Facilitator Guide, Counselor Manual and Client Workbook.
The Parent Child Assistance Program (PCAP) was developed by the University of Washington with a two-pronged approach:
- Case managers provide extensive role-modeling and practical assistance directly in the home.
- Client is connected to a comprehensive variety of services in the community, assuring that they actually receive the services they need.
Many women who participate in PCAP already have an alcohol-impacted child or themselves have FASD. Leah stresses that the key is the relationship of trust formed between the health professional and the woman being supported.
Three theoretical bases – Relational Theory, Stages of Change, and Harm Reduction – guide the PCAP interventions.
- “The PCAP model holds that the relationship between case manager and client is central to the success of the intervention, because it is an important path through which change occurs. PCAP puts the concept of relational theory into practice by offering personalized, knowledgeable and compassionate case management for three years, a period of time long enough for the process of gradual and realistic change to occur.”
- “PCAP case managers understand that for clients who have never experienced competence and accomplishment, each small step a woman takes deserves attention and encouragement. Acceptance and understanding of the client’s situation, and trust in the client’s perception and judgment, are critical.”
Potential obstacles to effective treatment include:
- Lack of awareness of FASD and of the need for AEP prevention efforts
- The view that some interventions are hard to understand or implement
- Not recognizing the special needs of each individual and tailoring treatment appropriately, especially where the pregnant woman herself has FASD.
Leah stresses that an important factor to remember is that interventions, whatever their cost, at this point are always cost effective in preventing costs of health support throughout the lifetime of an individual born with FASD.
Pediatric Care and FASD
In PART II of the webinar, Renee Turchi, MD, MPH, FAAP, looks at Pediatric Care, particularly the value of having a medical “home” for a client, with multi-disciplinary teams working out of one site to provide diagnostics, and of having continuity of care through a monitoring physician who holds a relational history with the family and child.
She introduces an FASD Toolkit intended to raise awareness, promote surveillance and screening, and ensure that all children receive appropriate and timely intervention.
She also shares FAQ page families and schools produced by healthychildren.org.
Healthychildren.org also has a risk communication video for families available here.
Substance Abuse Treatment and FASD
In Part III, Lisa Ramirez, MA, LCDC talks about her team’s experience with Substance-Abuse Treatment Issues.
Substance use disorder (SUD) intervention and treatment providers in Texas, where she works, have been trained in using the Screening and Modification to Treatment (SMT) approach developed by Dr. Therese Grant et al and published in the International Journal of Alcohol and Drug Research. The basis for the approach is the Life History Screen (LHS), developed by Dubrovsky, Whitney, Grant, which consists of 28 questions, 11 of which are in the Addiction Severity Index (ASI). LHS is intended to help providers modify treatments in order to improve outcomes among individuals with an FASD, their families, and the agencies that serve them; Lisa recommends this as an excellent resource
When asked about what she has seen as obstacles to recognizing these individuals, Lisa notes that there is a tendency to blame the patient if treatment does not succeed. Instead, she says, it is valuable, through an FASD lens, to examine how treatment fails the patient:
- To ask about maternal alcohol use and other indicators.
- To become familiar with brain differences, including linked behaviours and common co-occurring disorders.
- To identify patient strengths.
- To identify patient needs.
In discussing the question of what are some examples of how treatment for individuals identified with an FASD can be modified to appropriately address the disorder, Lisa notes that her team have identified a number of factors that work well for them in their practice:
- Some providers have made large structural changes, such as creating a “quiet room” for clients to de-stress and re-center; most changes are inexpensive and very easy to implement.
- Check for understanding by: using less clinical, more layman’s terms; checking in with the client on a more frequent basis; explaining the rules in clear language and showing the purpose of rules (e.g. “Random drug tests are done by staff to help identify problems early so we can help you achieve your goals.”
- Reinforce memory by assisting clients to program schedules and reminders into their phones and by making reminder calls first thing in the morning the same day of appointments where possible.
- Model positive behaviours, such as parenting skills and incorporate more role-play into sessions.
- Recognize stress: teach staff how to recognize signs that the individual is becoming stressed, including how to intervene appropriately.
- Use positive language (e.g. the form “Absence Policy” has been changed to “Attendance Policy”)
Lisa ends with a reminder that FASD-Informed Care is similar to trauma-informed care. It understands the likelihood of certain life experiences and allows for positive change to assist the client more fully and creates an atmosphere of individual service that carries over into other types of care provision.