Fetal Alcohol Spectrum Disorders: Key Services for Children in Foster Care

Lyn Laboriel MDJennifer LorsonLyn Laboriel, MD, Director, Fetal Alcohol Spectrum Disorders Clinic, LAC+USC Hospital
Jennifer Lorson, JD, Attorney, Children’s Law Center of Los Angeles (pictured)


Summary: The authors outline the challenges faced by children and youth with FASD and discuss services to effectively address them.



The court is an essential partner in identifying and treating children with FASD. The key to caring for children with fetal alcohol spectrum disorders (FASD) in foster care is to actively look for and identify them. The prevalence of FASD in the general population is between 2%-5% (May et al, 2009). A recent worldwide review of children in various childcare systems (e.g., orphanages, foster care) found that when FASD diagnoses are actively sought, the prevalence is nearly 17% (Lange 2013). Failure to make an accurate diagnosis early on puts children at risk for secondary disabilities due to incorrect diagnoses and ineffective intervention strategies. Early and accurate diagnosis with appropriately targeted interventions is essential (Streissguth et al., 2004).

Diagnosis, developmental and educational services, mental health services, and transitional support are foundational to the well-being of children with FASD. Judges are uniquely positioned to understand the needs of the child and to order child welfare agencies to ensure delivery of services to address those needs (Malbin, 2004; Burd, 2012).

Children with prenatal alcohol exposure are at high risk for FASD and should be referred for further assessment. All children entering foster care should be screened for FASD by medical providers trained to do so using established protocols (Astley, 2011). Judges should require child welfare agencies to provide birth records and other information about prenatal alcohol exposure, whether obtained directly from birth mothers or from other reliable witnesses.

Children with FASD often have neurodevelopmental deficits that last a lifetime and unfold over time (Paley, 2009). Infants and toddlers are at high risk for problems with sleep-wake cycles, feeding, language and speech, sensory regulation, attention, fine motor skills, balance, and toileting. Judges should refer these children for assessment by early intervention specialists in occupational therapy, physical therapy, language and early education (Carmichael Olson, 2007; Paley & O’Connor, 2009).

School-aged children face an array of neurodevelopmental challenges. These include: cognitive, adaptive, behavioral, learning and memory issues; deficits of attention and executive functions; and reductions in speed and efficiency of processing and sensory-motor issues—all often having serious impact on academic achievement and behavior (Paley, 2007). Judges should order assessments and special services provided through schools and other agencies. Detailed neuropsychological assessment may be needed to sort out the disabilities and strengths in order to design strategies for care (Carmichael Olson, 1998).

Since accessing both early intervention and special education services may be difficult if there is confusion about the holder of educational rights, the court can reduce the logistical challenges faced by caregivers by appointing an educational rights holder as soon as possible (Wang, 2008). Sometimes specialized advocates are needed to directly assist caregivers in obtaining services.

Children with FASD do best in safe, stable and nurturing home environments with reliable routines. The number of placements should be kept to a minimum. This can be difficult, because these children often present with challenging behaviors. Judges should encourage FASD training and support for caregivers. If family reunification is contemplated, parents should be required to undergo specialized training about FASD. In those cases, the court should also consider the need for screening birth mothers for FASD. Adults with FASD, despite good intentions, may have serious impairments in their ability to fulfill their own substance abuse treatments while undertaking the care of children with complex needs. Family reunification in these cases requires substantially more court-ordered support and monitoring for the family (Grant, 2007).

Mental health services by professionals who understand FASD are also critical. Children with FASD often have difficulties with self-regulation, attachment, relationships and sexual acting out (Carmichael Olson, 1998; Novick-Brown, 2007). Their adaptive and social skills are often delayed, if not in fact arrested, and require skilled intervention (Thomas, 1998; O’Connor, 2006). Combined with their exposure to abuse and neglect, serious behavioral challenges abound and can lead to frequent placement failures. The incidence of psychiatric disorders is significantly higher among children with FASD (O’Connor, 2002). The most effective behavioral interventions rely upon accurate diagnosis of neurodevelopmental roots of problem behaviors and providing intensive education and support for caregivers (Olson, 2006).

Foster youth historically experience great difficulty in transitioning to independence and youth with disabilities have particular challenges. (Geenan, 2006). For youth with FASD, the transition is made even more difficult because of poor adaptive and social skills, poor educational attainment, poor self-care skills and frequent encounters with the criminal justice system (Burnside, 2013). Extended foster care until age 21 can be an essential support, as can creative support programs designed for the special needs of this population (Child and Youth Officer, 2006). Many adults affected by FASD, even with the best of care, will need long term assistance with independent living (Spohr, 2008) and the court and child welfare agencies need to assist in devising plans for case management and assistance into adulthood.

Author biographies:

Lyn Laboriel, MD, is director of the Fetal Alcohol Spectrum Disorders (FASD) Clinic, part of the Violence Intervention Program at LAC+USC Hospital in Los Angeles. Dr. Laboriel is a developmental pediatrician working primarily with children in the Los Angeles County foster care system, a population of nearly 40,000 children. She provides both diagnostic services and ongoing supervision of FASD-related care through regular follow-up visits with families. She teams with others in the community to provide education and consultation as Los Angeles builds awareness and capacity to serve children with FASD.

Jennifer Lorson, JD, is an attorney with Children’s Law Center (CLC) of Los Angeles. CLC is a nonprofit law firm that primarily represents children in the Los Angeles dependency court system. She became interested in FASD related issues when she saw that many of her clients with FASD had never been diagnosed. As a result they were neither receiving adequate services, nor benefiting from traditional treatment models resulting in institutional living, failed placements and incarcerations.


References:

Astley SJ. (2011). Diagnosing Fetal Alcohol Spectrum Disorders. In: Adubato SA and Cohen DE (eds.) Prenatal Alcohol Use and Fetal Alcohol Spectrum Disorders: Diagnosis, Assessment and New Directions in Research and Multimodal Treatment, Bentham Science Publishers Ltd., pp. 3-29. http://depts.washington.edu/fasdpn/pdfs/astley- FASD-chapter2011.pdf

Burd L et al. (2012). Fetal Alcohol Spectrum Disorders (FASD): How Judges Can Improve Outcomes for Affected Children and Parents. CASA Judges’ Page. March 2012. http://www.casaforchildren.org/site/c.mtJSJ7MPIsE/b.7998249/k.6ED9/ JP_13_Burd_Herrick_Walker.htm

Burnside L & Fuchs D. (2013) Bound by the clock: The experience of youth with FASD transitioning to adulthood from child welfare care. First Peoples Child & Family Review. 8(1): 40-61. http://journals.sfu.ca/fpcfr/index.php/FPCFR/article/view/200/28

Carmichael Olson H, Feldman JJ, Streissguth AP, et al. (1998) Neuropsychological deficits in adolescents with fetal alcohol syndrome. Alcohol Clin Exp Res.22: 1998-2012. http://depts.washington.edu/fasdpn/pdfs/olson1998.pdf

Carmichael Olson H, Jirikowic T et al. (2007). Responding to the Challenges of Early Intervention for Fetal Alcohol Spectrum Disorders. Infants and Young Children. 20(2): 172-189. https://depts.washington.edu/fasdpn/pdfs/olson2007.pdf

Chen ML, Carmichael Olson H, et al. (2012). Sleep Problems in Children with Fetal Alcohol Spectrum Disorders. Journal of Clinical Sleep Medicine 8(4): 421-28. http:// depts.washington.edu/fasdpn/pdfs/CHEN-SLEEP2012.pdf

Child and Youth Officer for British Columbia. (2006). Special Report: A Bridge to Adulthood: Maximizing the Independence of Youth in Care with Fetal Alcohol Spectrum Disorder. 46pp. http://www.llbc.leg.bc.ca/public/pubdocs/bcdocs/406749/ bridgeadulthood.pdf

Frankel F et al. (2006). Stimulants, Neuroleptics and Children’s Friendship Training for Children with Fetal Alcohol Spectrum Disorders. Journal of Child and Adolescent Psychopharmacology. 16(6): 777-789. http:// www.americanbar.org/content/dam/aba/migrated/2011_build/child_law/ fasd_childrens_peer_relationship_training.authcheckdam.pdf

Geenan S, Powers LE. (2006) Are We Ignoring Youth With Disabilities in Foster Care? Social Work 51 (3): 233-241. http://sw.oxfordjournals.org/content/51/3/233.abstract

Grant, T.M., Youngblood Pedersen, J., Whitney, N., & Ernst, E. (2007). The role of therapeutic intervention with substance abusing mothers: Preventing FASD in the next generation. In: ADHD and Fetal Alcohol Spectrum Disorders (Editor: Kieran D. O’Malley) pp 125-60 Nova Science Publishers. Out of Print. Available online in Google Books.

Lange S, Shield K et al. (2013). Prevalence of Fetal Alcohol Spectrum Disorders in Child Care Settings: A Meta-analysis. Pediatrics. 132(4): pp. e980-e995. http://pediatrics.aappublications.org/content/132/4/e980.abstract

Malbin D. (2004) FASD and the Role of Family Court Judges. Juvenile and Family Court Journal. Spring 2004: pp 54-63. http://www.fascets.org/NCJFCJarticle.pdf

Mattson SN, Riley EP. (2011) The Quest for a Neurobehavioral Profile of Heavy Prenatal Alcohol Exposure. Alcohol Research Health NIAAA 34(1):51-55. http:// pubs.niaaa.nih.gov/publications/arh341/51-55.htm

May, PA, Gossage, JP et al. (2009). Prevalence and Epidemiological Characteristics of FASD from various research methods with an emphasis on recent in-school studies. Dev Disabil Res Rev 15: 176-192. http://www.ncbi.nlm.nih.gov/pubmed/19731384

Olson HC, et.al.(2009). Family Matters. Fetal Alcohol Spectrum Disorders and the Family. Dev Disabil Res Rev 15:235-249. http://depts.washington.edu/fasdpn/pdfs/ Olson2009.pdf

O’Connor MJ et al. (2006). A controlled social skills training for children with fetal alcohol spectrum disorders. J Consult Clin Psychol 74: 639-48. http:// www.ncbi.nlm.nih.gov/pubmed/16881771

O’Connor MJ, Shah B, Whaley S, et al. (2002). Psychiatric illness in a clinical sample of children with prenatal alcohol exposure. Am J Drug Alcohol Abuse 28:743-54 http:// www.ncbi.nlm.nih.gov/pubmed/12492268

Novick-Brown, Natalie. (2007). Sexually Inappropriate Behaviors in Patients with FASD. In ADHD and Fetal Alcohol Spectrum Disorders (Editor: Kieran D. O’Malley) pp 125-60 Nova Science Publishers. Out of Print. Available online in Google Books

Page KW. (2002). The Invisible Havoc of Prenatal Alcohol Damage Journal of the Center for Families, Children and the Courts. pp. 1-24. http://www.adp.ca.gov/perinatal/pdf/FASD_Kathryn_Page_PhD.pdf

Paley B, O’Connor M. (2007). Neurocognitive and neurobehavioral impairments in individuals with fetal alcohol spectrum disorders. Int J Disabil Hum Dev 6:127-42. http://www.americanbar.org/content/dam/aba/migrated/2011_build/child_law/ fasd_neurocognitive_and_neurobehavioral_impairments.authcheckdam.pdf

Paley, B. (2009). Introduction: Fetal Alcohol Spectrum Disorders – shedding light on an unseen disability. Dev Disabil Res Rev, 15, 167-169.

Paley B, O’Connor M. (2009). Intervention for Individuals with Fetal Alcohol Spectrum Disorders. Dev Disabil Res Rev 15:258-67. http:/ /onlinelibrary.wiley.com/store/10.1002/ddrr.67/asset/ 67_ftp.pdf;jsessionid=7BAA3AC31343D7CCFD85C1873B9D326E.f01t01? v=1&t=hoxcxt72&s=c093e0991362c67bb88cb3a068caf732d0a41847

Spohr HL. (2008). Fetal Alcohol Spectrum Disorders and their Persisting Sequelae in Adult Life. Dtsch Adztebl It 105(41): 693-698. Available in English http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2696967/

Streissguth, A. P., Bookstein, F. L. et. al. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Developmental and Behavioral Pediatrics, 25(4), 228-238. http://www.wisspd.org/htm/ATPracGuides/Training/ ProgMaterials/Conf2007/WEth/RFALO.pdf

Thomas SE et al (1998). Comparison of social abilities of children with fetal Alcohol Syndrome to those of children with similar IQ scores and normal controls. Alcohol Clin Exp Res 22(2): 528-32. http://www.ncbi.nlm.nih.gov/pubmed/9581664?d

Wang B (2008) New California Court Rules Protect Foster Child’s Educational Rights. Youth Law News. National Center for Youth Law. XXIX:3. http:/ /www.youthlaw.org/publications/yln/2008/july_september_2008/ new_ca_rules_protect_educational_rights/

Whitney N. (2012). Parents with Fetal Alcohol Spectrum disorders: Using the Neuropsychological Assessment as an Instruction Manual for Success CASA Judges’ Page. http://www.casaforchildren.org/site/c.mtJSJ7MPIsE/b.7998291/k.9B69/ JP_17_Whitney.htm

References for Care Givers:

Let’s Talk FASD: Parent Driven Best Practice Strategies in Caring for Children and Adults with FASD. From VON, Canada. (An excellent introduction to FASD interventions useful for caregivers and professionals. Downloadable easy to read 38 page booklet of practical guidelines and resources.) http://www.faslink.org/_fasdtool_fullproof2.pdf

 

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