YORKVILLE UNIVERSITY

Family-Based Treatment of Attention-Deficit Hyperactivity Disorder and Fetal Alcohol Spectrum Disorder in an Adolescent Male by Hannah Chapman McCormack

A MASTERS 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 Abstract

A 16 year-old adolescent male and his mother self-referred for treatment to cope with the adolescents 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 mothers 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 clients 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 familys stabilization and progress.

FAMILY TREATMENT OF ADHD AND FASD 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 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 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 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 Mothers 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 Todds 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.

Client names and other identifying features have been changed to protect their identity and privacy.

FAMILY TREATMENT OF ADHD AND FASD 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. Sons 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 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 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 Todds 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 Nancys 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 At age 13, Todd underwent a secondary psychoeducational assessment that refers to pervasive difficulties with verbal recall, attention, organization and focus. Todds adaptive

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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, Todds 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, Todds 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 Todds only other mental

FAMILY TREATMENT OF ADHD AND FASD health intervention as a child had consisted of family counselling for exposure to domestic violence.

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When Todd was 14 years old, Nancy admitted him to an inpatient adolescent psychiatric setting in response to extreme behaviours. Todds assessment included a renewed diagnosis for ADHD combined type. The psychiatrist believed that Todds 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 Todds symptoms to be worthy of separate diagnostic classification, rather he noted they were interwoven with Todds 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 Todds emotional distress. However, the most significant memo was that Todds family history strongly suggested a possibility of a Fetal Alcohol Spectrum Disorder (FASD). There were no notations for followup 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.

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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 Nancys 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 Mental status evaluation. At the time of the initial interview, both Nancy and Todd

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were coherent, lucid and appeared to be functioning at acceptable levels relative to their history. Todds 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, Todds 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. Todds 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, Nancys 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 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

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cheerful. There was no immediate sense of danger or any attempt on Todds 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 Todds ADHD and related behavioural and skills deficits while concurrently addressing Nancys 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 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 familys 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. Todds 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. Todds 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.

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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 Todds 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 Todds 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 FASNET assessment tool. The FASNET assessment tool (Berg, Kinsey, Lutke &

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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. Todds scores in all areas were extremely high, well within the 4 to 5 point range of multiple domains.

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Malbins (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 Todds 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 Nancys 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, Rnnestad, & 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 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

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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).

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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 patients reported history of characteristic symptoms and functional impairment, which must have been present at least since seven years of age, and a clinicians 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 problems in levels of neurotransmitter functioning, specifically dopaminergic communication

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(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 childs 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 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

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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 Kendalls (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 ADHDs lack of ability to attend for extended periods, smoothly

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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 Communication and social skills deficits. Robbins (2005) states that the

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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 selfstimulate 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 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

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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 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

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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

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simply medicating children, without teaching them skills they need to improve their behaviour and performance, is not likely to improve the childrens 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 childs 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 Behaviour parent training. Environmental and family influences can contribute to the

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severity of ADHD symptomatolagy in children (Ingersoll & Goldstein, 1993; Robbins, 2005). If parents do not understand that their childs behaviours are symptomatic of their ADHD, they tend to react to their childs 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 childrens 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 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).

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Children attempt to learn self-control via a number of activities like feelings awareness, thought monitoring, verbal self-instruction, problem-solving strategies, thought reframing, selfreinforcement, 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 followthrough.

FAMILY TREATMENT OF ADHD AND FASD Psychoeducational approach. Ramsay and Rostain (2005) stress the benefit of

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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 childrens 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,

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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 familys strengths develops rapport and maintains relationships. Interventions should be oriented toward the familys 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 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

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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 familys 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 childs 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 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.,

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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 childs 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 childs 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

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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 & OConnor, 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 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).

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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 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

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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; OConnor & 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 EF dysfunction impairs social and cognitive processes, which can lead to an increase in reactive and aggressive behaviour, impulsivity and attentional problems (OMalley & 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

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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 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

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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 4digit 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

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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-IVTR (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 (OMalley & 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 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.

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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 (OConnor & 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 symptoms as learning, thinking, physical responses to the environment and other behavioural

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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).

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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 selfesteem 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 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; OMalley, 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 ones life, (b) being diagnosed before the age of six, (c) never experiencing

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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 ones 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). OConnor 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. OConnor 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 regarding the relationship between childrens emotional adjustment and PAE, so that clinicians

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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; DOnofrio et al., 2007; Fryer et al., 2007; Leech, Larkby, Day, & Day, 2006; Lemola, Stadylmayr, & Crob, 2009; OConnor, 2001; OConnor, Kogan & Findlay, 2002; OConnor et al., 2006; OConnor & Paley, 2006; OConnor, 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, OConnor, & Paley, 2008). OConnor 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 (OConnor et al., 2002; Fryer et al., 2007) are limited by their small sample sizes; however, Walthall, OConnor, and Paley (2008) looked at 130 children with and without

FAMILY TREATMENT OF ADHD AND FASD 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

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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, OConnor, & Fitzgerald, 2001). It appears that the greater the levels of PAE, the higher the manifestation of lifelong irritability and depressive symptomatolagy in the children (OConnor & Kasari, 2000; OConnor & 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% (OConnor & 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. 235236).

FAMILY TREATMENT OF ADHD AND FASD Interestingly, paternal emotional support to mother and child seems to be a protective

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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, OMalley & 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). DOnofrio 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 sameaged peers and are overrepresented in psychiatric samples, juvenile detention centres, and correctional settings (Burd, Selfridge, Klug, & Juelsom, 2004; Conry & Fast, 2000; OConnor, 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,

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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 childrens moods and temperament. In their study on the association between PAE and insecure attachment, OConnor, Sigman, and Brill (1987) found that the majority of infants whose mothers drank heavily in pregnancy displayed insecure attachment. OConnor 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, OConnor, 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 children (Putnam, 2006). Trauma can alter the development of the bodys 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

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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 BlackPond (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

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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 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,

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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 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; OMalley &

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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 OConnor (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; OConnor 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 (OConnor & 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 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

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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 clients 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 (OMalley, 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 possible. Unfortunately, the important window of opportunity for early intervention is often missed and children remain untreated until their teens or adulthood (OConnor & 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. BPTs 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

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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, OConnor, Frankel, & Marquardt, 2006). Parents of individuals with FASDs benefit from receiving both relationship focused, and behaviouroriented intervention programs (Bertrand, 2009). OConnor 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 (OMalley, 2007). However, OMalley (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 individual situation is more effective than assuming a client can learn from theory and apply it outside of session (Novick & Streissguth, 1995).

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Caregivers also need to work on altering their cognitions and attitudes about the meaning of their childrens behaviour. Therapists can help parents to reframe their understanding of behaviours as a symptom of the childs 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; OMalley, 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 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 & OMalley, 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,

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2009). In addition, assisting parents to create timetables and schedules, or making picture charts for desired behaviour is valuable (OMalley, 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 Malbin emphasizes that individuals with FASDs need support throughout their life to

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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. OMalley (2007) believes that treatment of FASDs requires a multimodal, flexible approach that incorporates new strategies on a continuing basis. OMalley 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 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

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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 childs needs (Dunst, 2002). The caregivers of a person with a FASD are the most permanent forces in the childs life and are in the best position to be the childs 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 workers 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:

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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 Psychodynamic strategies. Role-play and rehearsal are creative ways of teaching and

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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). OMalley (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.

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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

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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 parents desire interaction with other parents.

FAMILY TREATMENT OF ADHD AND FASD 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

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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). OMalley (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 childrens 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 (OMalley, 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

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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 clients 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 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

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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, OConnor 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

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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; OMalley & Nanson, 2007). OMalley 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 LDs 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 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,

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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 (DOnofrio et al., 2007). OMalley 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 (DOnofrio et al., 2007; OMalley & 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 ADHD but less on treating FASDs. However, many of the treatment approaches put forth for

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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 therapists attitude should be dynamic, direct, brief, encouraging, and affirming (Harwood & Eyberg, 2004; Nadeau, 2005). Complex cases, such as Todd and Nancys 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, selfregulation 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 Todds challenging

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behaviours. If left untreated, the familys 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. Todds 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 Todds 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. Todds major psychiatric assessment at age 14 linked Todds substance use, challenging behaviour, and sporadic anger

FAMILY TREATMENT OF ADHD AND FASD outbursts to his ADHD, past trauma, poor parent-child attachment and various environmental triggers.

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Todds 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. Todds 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. Todds reports all had recommendations for individual therapy, life and social skills training, and BPT for his mother. Suggestions for Todds 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

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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 Todds major psychiatric report at age 14, his psychiatrist questioned whether his profile was consistent with PAE and/or a FASD. Todds 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; OMalley & 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

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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 (OConnor & Kasari, 2000; OConnor & 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 Todds 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 ones own behaviour and hinders brain development (Perry 1999; 2002). This could explain why Todds adaptive functioning was so low, and his symptoms were so severe (Henry et al., 2007).

FAMILY TREATMENT OF ADHD AND FASD Children with PAE and trauma manifest the most severe range of brain dysfunction (Barthel & Nickel, 2009; Henry et al., 2007). Upon intake to therapy, Todds 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 Todds extreme challenging behaviour, his mental health

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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 Todds multiaxial assessment based on initial case information. Todds 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 314.01 V61.20

DSM-IV Name Attention-Deficit/hyperactivity disorder, Combined type Parent-child relational problems

FAMILY TREATMENT OF ADHD AND FASD Axis II: Personality Disorders and Mental Retardation None Axis III: General Medical conditions None Axis IV: Psychosocial and Environmental Problems Category Problems with primary support group Problems related to social environment Educational problems Occupational problems Housing problems Economic problems Access to health care services Interaction with legal system/crime Other psychosocial and environmental problems Axis IV: Global Assessment of Functioning Score: 50

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Specifications Attachment/relational issues with parent Easily manipulated/hard time making real friends Truancy, suspensions, poor grades Terminated from employment frequently Family moves frequently for not paying rent Mother works part-time and receives no spousal support Confusing to family, need assistance Offences made, court hearing, probation Alcohol and Cannabis misuse

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 foundation, I could work towards stabilizing the familys level of functioning and towards enhancing their diminished coping ability (Davis et al., 2008). Main therapeutic approach. This familys issues were multi-faceted, complex, and stretched across multiple domains. Bernstein (1996) recommends that therapy for those with

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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, OMalley (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 Therapeutic adaptations. Adaptations to traditional therapy were necessary to accommodate Todds 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 familys 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.

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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 Todds care would allow her to help him practice new skills outside of therapy (Pelham & Gnagy, 1999). Todds daily environment and the expectations of those around him had proven to be more than he could handle. Kendall et al. (1990) affirm that underachievement 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

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FASDs (Abikoff, 1991; Fabiano & Pelhmam, 2003; Famy et al., 1998; MTA Cooperative Group, 1999; OConnor 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 Nancys 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 Todds 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 Todds 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 Todds 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.

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Overall, I decided to implement a multi-modal therapy approach (see Table 1), tailored to Todds needs, that was family-centred and strengths-based in its delivery (Vargas & Prelock, 2004). I developed Todds 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: Todds Therapy Treatment Plan
Intervention Modified CBT/ Psychoeducation Details Psychoducation on ADHD and FASD and their affect on behaviour, CBT to increase self-concept, target negative and anxietybased cognitions, reframe thoughts, enhance awareness of feelings, teach problem solving and self-instruction Literature Support 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

Life and social skills training

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.

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 & OMalley, 2000; Walthall et al., 2008; Wiggins et al., 1999

Self-regulation training

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; Benson & Havercamp, 2007; Bertrand, 2009; Douglas, 2005; Foxx, 2003; Malbin, 2008; Moore & Green, 2004; Morrissette, 2001; Novick & Streissguth, 1995; Perry, 2006; Selekman, 2010: Streissguth & OMalley, 2000; Walthall et al., 2008

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Self-esteem and strengths building/self-advocacy training To enhance interpersonal relationships, self-worth and the capacity to self-advocate

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Brown, 2000; Edwards, 2002; Glass & Myers, 2001; Hanna et al., 1999; Lennox et al., 2004; Nadeau, 2005; Okie, 2006; PortieBethke 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 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 To give service providers a proper blueprint for intervention and support

Davis et al., 2008; Weinberg et al., 2008

Address substance misuse

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

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 Todds treatment plan as the most permanent force in his life (Dempsey & Keen, 2008). If Nancys 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). Nancys frame of mind and her moods affected Todds 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; OConnor & Paley, 2006). My goal was to work in small steps, and celebrate all

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successes. I knew it would be important not to get ahead of Nancys desired pace if I wanted her to stay in therapy. Table 2 shows Nancys treatment plan. Table 2: Nancys Treatment Plan
Intervention Adapted Individual support Details and Aims 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 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 Literature Support Chromis et al., 2004; NCDSS, 2004; OMalley, 2007; Sonuga-Barke et al., 2001

Group peer support

Booth & Booth, 1993; Liptak et al., 2006; OMalley, 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 removed or adjust inflammatory triggers in the childs environment to reduce conflict. As a

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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 Todds 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 Adapted Behaviour Parent Training and Collaborative Helping Model interventions to increase healthy attachment Details and Aims 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; Literature Support 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 & OMalley, 2000 Schubiner, 2005 Acro et al., 2004; Bertrand, 2009; Green, 2007; Levine, 1995; Nadeau, 2005; Lennox et al., 2004; Malbin, 2008; OMalley, 2007; Ramsay & Rostain, 2005; Selekman, 2010; Vig & Kaminer, 2002

Role-model positive behaviours Psychoeducation on Todds diagnoses and their impact on behaviour and functioning

Stop substance misuse in front of Todd Developing realistic expectations for Todd and for therapy; understanding the link between brain dysfunction and behaviour; taking Todds developmental dysmaturity into consideration; making allowances for Todds slow processing speed by giving extra time; become an advocate for Todd; learning coping tools; increasing Todds 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

Environmental Accommodations

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 Work with other professionals. A multidisciplinary treatment approach is recommended in the literature when working with brain dysfunction (Devries & Walder, 2004;

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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 Todds 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, Todds probation officer only saw him once a month as he worked

FAMILY TREATMENT OF ADHD AND FASD 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

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work in conjunction with Todds probation officer to help Todd adhere to his probation rules and expectations as Todds 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 Todds 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

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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. Nancys sessions. Nancys 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 sons 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 Todds 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 Session two: In our second session, Nancy and I started a dialogue on how brain

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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 Todds 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 Todds 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 Todds 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

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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 Todds 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 exercises to practice. I told them these communication rules would be on the white board whenever we did joint sessions to remind them.

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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 others 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 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.

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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 Todds 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 Todds high school had said he could not return due to multiple suspensions for truancy. I recommended that the family start the paper work for Todds 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.

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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 Todds 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. Nancys 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 Todds 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 problematic for Todds 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

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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 selfregulation 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

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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 Todds 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 Todds probation officer. I agreed stressing that sentencing by a Judge should recognize the presence of Todds 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 Todds 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 Todds brain works in addition to new parenting skills. Todds 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 Session one: My first individual session with Todd was deliberately set-up to be

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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 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 Todds recognition that many of the people he considered friends did not have

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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 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

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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 Todds 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 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

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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 selfregulation, 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 Todds 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 Nancys 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 Todds upcoming court date.

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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 Todds 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 Todds 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 Todds 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 Todds probation officer to speak with him about court the following week. Before this session, I had spoken on the phone with Todds legal aid

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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 Nancys request, I asked Todds lawyer to suggest to the Judge that Todd attend a residential program for adjudicated youth where he could get uninterrupted counselling and support. Todds 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 Todds probation officer at the courthouse for Todds 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

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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 Todds assessment for a FASD completed. The assessment appointments occurred over two days and Todd saw a psychologist, psychiatrist, paediatrician and social worker. Todds sessions. The month after court, while waiting for Todds 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 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

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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

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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 Todds 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 Todds individual strengths. I normalized their feelings and worries about the

FAMILY TREATMENT OF ADHD AND FASD 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

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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 Todds 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

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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 Nancys 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 Todds ARND and ADHD affect his vocational abilities. Session seventeen: Between sessions, I had contacted Todds 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.

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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 Todds 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 Todds 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

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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 Todds 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 Todds transition back to the community. Todds 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

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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 familys 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 Todds 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 replacement as I was leaving my position to move to another city. Andrea continued to work

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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 Todds behaviour was escalating to harmful levels. Through our work together, I believe the familys functioning became more stable as evidenced by a reduction in the intensity of their conflicts, as well as an increase in knowledge of how Todds 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 Most importantly, when Todd and Nancy first came to session they did not really understand

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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 Todds 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 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

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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 Discussion Personal Reactions to the Case

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Working with Todd and Nancy was one of the biggest challenges of my life. At times, I felt frustrated by the familys lack of progress and with Nancys 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

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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 selfadvocate 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 Implications for the Field

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I think Nancy and Todd also came to realize that many of Todds 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 Todds 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.

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FAMILY TREATMENT OF ADHD AND FASD 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

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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

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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).

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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 Appendix B: Counselling Sessions Rating Scale

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