Master Clinician Note: Serena is presenting high-risk behavior by combining alcohol use and unprotected sex. The counselor seeks to identify the link between alcohol, unprotected sex, and pregnancy.

Master Clinician Note: Serena has made it clear that she does not want to become pregnant, so the counselor shifts to addressing the gap between Serena's behaviors (being sexually active but not practicing safe sex) and her stated desire (to not get pregnant).

Master Clinician Note: This vignette does not “solve” the issue of Serena's depression. However, as part of examining the possible causes, Serena has talked about a pattern of regular at-risk drinking, combined with unprotected sex. Because of this, the counselor—who by now has established a good rapport with Serena—has taken the opportunity to carefully include a selective intervention for preventing an AEP.

In an informal way, the counselor has used the steps of the “FLO” intervention discussed in Part 1, Chapter 1 of this TIP. During intake and again at this visit, Serena has indicated that she consumes alcohol and is sexually active. The counselor provides Feedback on these responses (by discussing the possibility of an AEP), then Listens as Serena indicates that she does not want to become pregnant. The counselor thus shifts the focus of medical advice to the Option of contraception and provides Serena with educational material.

At the same time, the counselor has not lost sight of depression as Serena's primary treatment issue. In this session, the counselor has laid the groundwork for continuing to discuss Serena's at-risk drinking and her problematic relationship with Rob as possible components of the depression, but in the context of positive goals that Serena can aim for (i.e., finding ways to feel less depressed, fight with Rob less, and avoid an unwanted pregnancy).

Master Clinician Note: The counselor uses the visual below to help Chloe more concretely understand her level of consumption. However, this visual does not reflect every available drinking size or container, so any discussion of a standard drink should incorporate the client's personal experience (i.e., “If you don't see your glass on here, what do you use?”).

Master Clinician Note: The counselor expresses empathy for the client and how sad/worried she is feeling. This expression of empathy assists in establishing more of a caring relationship, so that further questions around alcohol use can be explored in a helpful manner. The counselor also explores more with the client about how she is feeling when she talks about “taking the edge off” to see what might be the result of her drug use and to see if she needs a mental health evaluation. A mental health evaluation might explore whether medication is indicated that could assist Chloe in reducing her alcohol use.

Master Clinician Note: The counselor does not assume that the client is deliberately underestimating, but keeps in mind that clients may minimize when self-reporting alcohol use (Taylor et al., 2009).

Master Clinician Note: Given the frequency of poly-drug use among clients in substance abuse treatment, this counselor did not assume that methamphetamine was the only substance that Chloe was using. Through some simple probing, the counselor has identified that not only has Chloe been drinking, she has been doing so at a high-risk rate. At a future time when dealing more specifically with the amount Chloe is drinking, the counselor might show her a chart with drinking frequencies to help Chloe see what level of drinking is defined as heavy and/or problematic for women.

Chloe has also talked about a pattern of self-medication. The reason or trigger for this may be depression; Chloe has said only that she drinks when she is “feeling like s&@*.” This will require further exploration. For now, the counselor knows that a potential co-occurring mental health issue, a co-occurring substance abuse issue, and prevention of a possible AEP should all be factored into the treatment plan.

Master Clinician Note: The practitioner has included alcohol as part of a general health exploration rather than asking the question by itself, which can make some clients nervous. Still, April looks a little concerned.

Master Clinician Note: This interaction demonstrates the value of re-screening in relation to alcohol. April stated in the first visit that she does not drink. However, during this second visit, she has revealed that she does drink on occasion. It will be important for the practitioner to repeat the benefits of abstinence during pregnancy and probe for level of alcohol use, while remaining supportive and nonjudgmental.

Master Clinician Note: The practitioner can use a visual aid, as in the previous vignette, to help April understand how much really equals one drink. The practitioner has also repeated the importance of abstinence during the pregnancy, and tied the guideline specifically to the health of April's baby.

Master Clinician Note: Given that April has continued to drink even after her first couple of visits, the practitioner takes the educational process a step further this time, clearly noting that science has established a risk and that there is no “acceptable” form or amount of alcohol. A counselor or practitioner may also want to discuss the possibility of equipping April with some tools to help her abstain during the pregnancy (e.g., relaxation techniques, recreation, avoiding trigger situations such as parties). The need to continue to monitor April's alcohol consumption should be clearly noted in the medical record.

Master Clinician Note: The counselor wants to reassure Isabel that she has not formed a negative opinion of her. The counselor now also needs to be aware that Isabel may try to minimize the frequency and amount of alcohol consumed so that she is not viewed as an alcoholic.

Master Clinician Note: The counselor wants to get an accurate picture of Isabel's drinking during pregnancy, so she brings out a calendar. The visual is helpful as it allows both client and counselor to put their eye contact elsewhere, which can contribute to the ease of discussion. The counselor explains that it also helps to trigger memory by looking at dates.

Master Clinician Note: The counselor senses that Isabel is getting a little anxious about this line of questioning and tries to be reassuring and non-judgmental.

Master Clinician Note: The counselor is gradually asking more detailed questions about Isabel's alcohol use. Although Isabel claims not to be a drinker, a pattern of usage is emerging through the use of the calendar. Isabel is bringing up Marco often, so the counselor takes this cue and probes further about her husband.

Master Clinician Note: Isabel is becoming anxious, and is shifting the topic away from alcohol. This is a signal, or cue, to the counselor that the client is uncomfortable. The counselor needs to acknowledge what Isabel is feeling and be careful about how much further she probes on this issue during this visit.

Master Clinician Note: The mental health counselor is in a difficult position. Her use of the calendar helped to reveal a pattern of alcohol use by Isabel and her husband that exceeds what Isabel first admitted and is unsafe for the baby. It also helped to establish some of Isabel's triggers for drinking alcohol, which include her husband and being angry.

At the same time, discussing alcohol use and how it can hurt a baby can be an emotional topic for the mother. She is working hard to take care of her baby, and the topic of alcohol may have gone further than she is comfortable with. At the same time, it has been useful, as Isabel seems to be reaching a point where she has begun to question her use of alcohol during pregnancy.

This is a learning moment for the counselor. She can see the value of exploring alcohol use with her pregnant patients, but she also knows that, in the future, she can pay closer attention to verbal cues that indicate a client's discomfort; in Isabel's case, the changing of the topic and the repeated assertions that she doesn't think she has hurt her baby. The counselor should continue the session long enough to bring closure to the topic of alcohol use, while supporting the positive things that Isabel has done to take care of her baby. The door should be left open to come back to the topic of alcohol in future sessions.

If Isabel continues to show a pattern of alcohol use during the pregnancy, the counselor can help her identify other ways to deal with her anger besides drinking (stress management), and help her identify or find support systems in her life other than her husband if he is not being supportive of her abstinence during pregnancy (e.g., a pregnancy peer support group). If a mental health counselor does not feel comfortable addressing these issues, referral to a qualified substance abuse treatment counselor is advisable.

Master Clinician Note: Individuals with an FASD sometimes exhibit poor working memory. The health care worker is not assuming that Marta has an FASD at this point. However, if she does, it is unlikely that she will remember the information about the bus route, so the health care worker writes it down.

Master Clinician Note: Marta has exhibited a double “red flag” for an individual with an FASD; poor money management skills, and a lack of understanding of consequence (i.e., giving away the money without understanding that she then wouldn't be able to pay for the bus).

Master Clinician Note: Marta is exhibiting very literal interpretation of language, which is common among individuals with an FASD.

Master Clinician Note: Marta has stated that she understands when really she doesn't. Any young person might do this, but it is especially common for individuals with an FASD. Checking for cognition is important with clients that have or may have an FASD.

Master Clinician Note: Because this is an interview to see if there is reason to believe that Marta has an FASD, the counselor is probing to see if perhaps Marta's baby was also exposed to alcohol before birth.

Master Clinician Note: It is not unusual for individuals with an FASD to no longer be in the care of their parents, and to have been placed multiple times in foster care.

Master Clinician Note: Time spent in the “resource room,” while not a clear-cut clue, is certainly a strong indicator that the child was identified in school as having special needs. This is often the case with children who have an FASD. The counselor could further explore by asking a follow-up question like “Did you ever have extra help with your school work?” or “Did you ever have special classes or tutoring in school?”

Master Clinician Note: Involvement in “trouble” or crime as an unintentional secondary participant is an FASD “red flag,” particularly when the motivation is social (i.e., to make friends).

Master Clinician Note: Marta's case/vignette is oversimplified. In a matter of minutes, she has exhibited a handful of behavioral clues that suggest that she may have a disability. Not all individuals who may have an FASD will be this easy to ‘spot.’ This conversation is provided simply as a way to learn how such “red flags” might come up in conversation with a client. By identifying these red flags, which are particularly common in individuals with an FASD, the health care worker will be able to manage the case in a way that better suits the needs of the client, and can make a better-informed decision regarding the need for a more complete FASD diagnostic evaluation. Additional probing questions that could be asked include the following:

• How much alcohol did your mom drink when she was pregnant?
• Think about when you were a child. How did you do in school?
• Do you ever have trouble keeping appointments? How do you do with telling time?

Refer to Part 1, Chapter 2 for guidance on referring a client for a formal FASD diagnostic evaluation, and for strategies and treatment modifications that will improve treatment success with an individual who may have an FASD.

Master Clinician Note: It's important at this point for the mental health professional to respond to the fact that the client is feeling blamed and becoming agitated.

Master Clinician Note: It is advisable to provide FASD information that does not include pictures, particularly of children with prominent facial dysmorphology (e.g., thin upper lip, smooth philtrum). These facial characteristics are present in only a small percentage of children who have an FASD, and if the client's child does not resemble the children in the pictures, this may enable the client's desire to believe that their child can't possibly have an FASD.

Master Clinician Note: Although the mental health professional makes repeated attempts to assure Dixie that she does not need to feel blame about the possibility that Jarrod has an FASD, Dixie has still become upset. This is a very natural response, and counselors should be prepared for birth mothers to feel as though they are being ‘blamed’ for their child's condition when FASD is discussed. However, many pregnancies are unplanned, some doctors do still recommend a glass of wine as a way for a pregnant woman to relax, and many women do not realize until well into their first trimester that they are pregnant. The mental health professional utilizes these realities as a way to reassure Dixie and disconnect her from a sense of guilt and consistently reiterates their shared goal, to find the best way to help Jarrod. She also effectively coordinates care by putting Dixie in touch with additional testing and offering a support group number.

Master Clinician Note: The counselor is listening to everyone in order to validate the feelings and concerns of all individuals attending the session.

Master Clinician Note: It is advisable for the counselor to caution the client and all attending the session that the quality and reliability of online information about all forms of FASD varies. She should provide the client with a reading list of up-to-date sources, but advise them to put it down when they need a break to avoid feeling overwhelmed.

Master Clinician Note: The counselor can now review the report with Jenine and her support persons. The counselor can use the review to assess the knowledge level of the client and her sister and elder, in order to determine how much education and support will be needed throughout the process. It is also advisable to inquire about other family members (grandparents, brothers, sisters, aunts and uncles, extended family) to assess how they will feel about the child's disability and to gain insight into cultural differences.

A sample Medical Summary Report can be viewed at the Web site of the Washington State FAS Diagnostic & Prevention Network (FAS DPN): http://depts.washington.edu/fasdpn/pdfs/4-digit-medsum-web-2006.pdf.

After completing the review, the counselor should focus on Brice's priority problem area, as well as the most significant need(s) of the caregiver.

Master Clinician Note: Even though answers to these questions cannot all be provided immediately, the counselor assures the client that they will work together to establish plans to address them.

Master Clinician Note: A diagnosis of any form of FASD can be overwhelming for a family. Although this vignette lacks specifics, the overarching theme of importance is that the counselor is positive, is willing to work with the family to make a plan to address any areas of concern, and is available to help them through the process. For families and caregivers of an individual with an FASD, having this navigational assistance can be tremendously helpful and relieve much of the stress that can go along with caring for such an individual. In addition to addressing the areas identified by the family as priorities, it will be important in future sessions for the counselor to:

• Consistently point out the child's positive attributes;
• Recommend a specific support group for the family, if available;
• Emphasize the need for respite care; and
• Ask the client about ways to involve the child in an area of interest, like music or sports or art. This can provide a ‘break’ for both the child and the caregiver.

Master Clinician Note: Yvonne is clearly confrontational. The counselor is navigating around the resistance by not repeating questions and insisting on answers, and changing the physical environment to one that Yvonne chooses. The counselor then begins a rapport-building process by holding off on treatment talk in favor of getting to know Yvonne personally.

Master Clinician Note: The counselor should not leave it at “I don't know,” but probe further. With a client who has an FASD, the probes should be very specific.

Master Clinician Note: The counselor does not merely ask “Does that look okay?” but also asks a follow-up question to make sure Yvonne understands. Since this is a client that has been noncompliant with medication, the counselor also schedules another session at an early date to reinforce the new plan, rather than waiting a week or longer.

Master Clinician Note: The counselor has employed a number of steps to build rapport, avoid confrontation, and simplify processes for a client that has an FASD:

• Although clinicians are trained to ask open-ended questions, this counselor made the questions quite specific. For example, when the question “How has everything been going?” got no response (it's a fairly abstract question to someone with an FASD), the counselor avoided confrontation and switched to something specific: “Have you been taking your medication?”
• The counselor never used the word “why.” A person with an FASD will most likely struggle with understanding or communicating their motivations.
• The counselor limited choices to avoid overload; for example, instead of “What would you like to do?” the counselor offered a specific choice: “Would you like to walk around the courtyard, or go to the cafeteria?” This simplified the choice for Yvonne, and also changed the environment to one she likes, allowing her to share a little more easily.
• The counselor broke down the medication plan into small chunks, wrote them down, and reviewed the steps one at a time with Yvonne. If Yvonne had not seemed to be grasping the plan, the counselor could have considered reviewing it several more times, or even role-playing to solidify each step.
• The counselor scheduled a quick-turnaround follow-up visit so as not to lose valuable time if the plan isn't working, and is bringing the mother into the process as reinforcement.
• Lastly, the counselor built rapport and found a common ground around something that Yvonne really enjoys, her pets.

Master Clinician Note: Mike's thoughts are somewhat discursive due to stress, and perhaps due to grief about the challenges of his son's upcoming life transition. Creating safety protection for Desmond is an important way to help Mike, but the counselor should remain aware that Mike also has his own needs. Research shows that caregivers have many unmet family needs, often focusing on dealing with the emotional aspects of caregiving. The counselor is allowing Mike to express all sides of the situation. This includes negative feelings, but the counselor is also listening for signs of positive “expressed emotion,” deemed to be a protective factor. The counselor is also thinking about how to promote caregiver self-care.

Master Clinician Note: Clinical wisdom, and now some new interventions for caregivers of adolescents and young adults with FASD, such as the Partners for Success Program (information available through the CDC-funded FASD Regional Training Centers), hold that mentors can be very useful in intervention. Mentors can be community college students, aides who work in developmental disabilities services, younger relatives or family friends, or students studying to work in social services. A mentor is someone who can act as a very competent peer or a caregiver closer in age to the affected individual. They can build an ongoing and positive relationship, be available for check-ins to provide input and guidance on solving problems with peer relationships and lifestyle problems, and work toward helping the affected individual become more self-aware. They may also be able to connect the individual to pro-social and competent peers, and help find appropriate, positive recreational activities for leisure time.

Master Clinician Note: For parents of individuals with developmental disabilities, it is very helpful to be proactive. At the same time, “looking forward” is an emotional process. The clinician will have to judge how far ahead the caregiver really wants (and needs) to plan. The clinician also needs to use reflective listening and summary statements to help the caregiver process their own emotional reactions as they do future planning. Beyond this, the clinician can help caregivers plan ahead in a practical way. Because Desmond is a young adult (though functionally an adolescent), and is starting to build an independent life, the clinician can coach Mike on how to help Desmond self-advocate and self-monitor.

One important direction is to coach Mike in creating concrete, behavioral “benchmarks” for his son, so Desmond can show daily or weekly progress and also show his father that he is ready for this life transition. This could include practicing things such as buying groceries as if he were already living on his own, and/or troubleshooting, such as thinking out loud about what to do in real-life situations—e.g., if he gets sick, the toilet starts overflowing, etc. If Desmond resists doing this (which would not be unlikely given his functional age), the counselor can work with father and son to integrate rewards for Desmond after he shows certain behaviors or masters specified tasks. An age-appropriate reward for someone functioning at an adolescent level could be more ‘space,’ i.e., increased time between check-ins from his father after Desmond demonstrates mastery.

Mike has educated his son carefully about drinking, which is good, but he should think about other areas he needs to talk about with Desmond, as well, including 1) safe sex; 2) communicating clearly with partners about consensual activity; 3) use of cigarettes; 4) use of illicit substances, such as marijuana and other drugs; 5) the consequences of criminal activity; and 6) ideas on what to safely do when Desmond has times of feeling irritable and negative (calming strategies).

Master Clinician Note: Choice and level of language used on Safety Cards will differ depending on the intellectual level of the individual with an FASD. Areas of safety concern may include:

• Household reminders (buying groceries, paying bills, cleaning the apartment, taking out the trash, maintaining personal cleanliness, etc.)
• Useful phone numbers (advocates, police, hospital, primary providers, etc.)
• Transportation (routes, times, and costs)
• Work and school schedules
• Personal and household safety reminders (turning off appliances, locking doors and windows, etc.)
• High-risk behavior warnings (e.g., unsafe sex, alcohol or drug use, getting really irritable and upset)

There are programs for caregivers raising affected youth that have other useful ideas for ways to plan ahead (e.g., the Families Moving Forward Program and Partners for Success Program).

Master Clinician Note: Research on FASD and, more generally, on developmental disabilities has uncovered important protective factors. Many of these are well-known, such as positive family and peer relationships, appropriate social services and freedom from substance abuse by the individual, peers, or family members. Other protective factors may be less obvious but are no less important. For the caregiver, these include decreased stress and depression, a sense of parenting efficacy, positive expressed emotion and a viewpoint on the affected individual, and adequate caregiver support and self-care. For the affected individual, these include a willingness to ask for (and value) help from others, positive, time-filling extracurricular activities, adequate and refreshing sleep, connections to pro-social and competent peers, a positive self-perception, a sense of meaningfulness through activities such as a job, talents that others recognize and value, spirituality, and more.

Master Clinician Note: This session shows what it is like to work with the caregiver of someone with FASD. A possible future session could include Desmond's aunt and the coach, to create advocacy or “look-out” tasks they could all divide up to help Desmond stay organized while Desmond first starts living on his own. In sessions that include Desmond, the clinician will need to change pace and style. Specific ideas that would help Desmond, and can be used with most other affected individuals:

• Work with the affected individual to identify his or her goals, including how to generate an effective goal, “mini-steps” to achieve the goal, and needed supports.
• Discuss warning signs that they need help.
• Discuss and practice through role-play how to ask for help.
• Create a written Crisis/Safety Plan.

This vignette would play out differently depending on the culture and ethnicity of the caregiver and youth. Research shows there are different expectations for independence and type of family relationships in different cultures. This interacts with the impact of developmental disabilities. In some cultures, for instance, adult children are not expected to move out of the family home, though they will still increasingly assume more leadership and adult responsibilities within the family. In cultures where the extended family tends to be closer, affected individuals may have more resources and support from relatives, or a greater likelihood of available peer models to serve as caregivers or mentors. Research also shows that some protective factors may differ by culture: Attachment to and identification with the values of one's culture of origin is a protective factor for immigrant youth. Yet this can also be a risk: Data suggest that these youths may also be at higher risk for marginalization and discrimination. Recommending involvement in culturally relevant and pro-social leisure time activities can be a productive way for an individual with an FASD to learn about their own culture.

Master Clinician Note: Whether intentional or not, the birth mother of a child with an FASD can be perceived negatively by others, including educators, for having “caused” her child's disorder. The social worker is gently preparing Denise for this possibility and reinforcing the positive nature of how she advocates for her child.

Master Clinician Note: If the social worker cannot attend an IEP meeting with the client, they should still encourage them to have a support person with them, if at all possible; someone else who is familiar with the caregiving situation.

Master Clinician Note: Denise is clearly frustrated with the educational process, and this is understandable. At the same time, the social worker is tempering this frustration and laying the groundwork for a more successful IEP meeting by helping Denise remember the reasons why annual meetings are worthwhile even if difficult. For the meeting itself, the counselor makes the following suggestions:

• To spotlight the child's aptitudes and hobbies, bring pictures of the child enjoying these activities and/or examples of things they've done or created (e.g., artwork, crafts).
• Parent should be encouraged to “catch more flies with honey than with vinegar.” The parent's frustration with the system as a whole should not be targeted at the individuals on the other side of the table.
• Parent should approach the meeting with a mindset of using statements such as “My child needs…” rather than “I want my child to…” The federal law is for educators to meet the child's needs, not the parent's wishes.

Master Clinician Note:

• Example 1: Federal law limits schools in terms of sanctioning children who act out as a result of a disabling condition, such as an FASD. If the child is acting out, a Behavioral Modification Plan should be considered instead.

Master Clinician Note:

• Example 2: Watch for cases when bad behavior is a result of modeling other children with behavioral issues.

Master Clinician Note:

• Example 3: Work with the educational staff to think “outside the box” when it comes to accommodations.

Refer to Part 1, Chapter 2 for additional guidance on educational accommodations for individuals with an FASD who are still in school.