Wednesday, 6 December 2017

Interpreting FASD diagnostic practices and treatments

On December 14, 2015, the Canadian Medical Association Journal published an article called "Fetal Alcohol Spectrum Disorder: A guideline for diagnosis across the lifespan" which was a revision by the same authors to an earlier article published in 2005.  While these guidelines are not necessarily required to be followed by medical practitioners, they are the most widely used and accepted.  These Canadian guidelines are a little different from other countries primarily because the medical community isn’t currently agreeing on the meaning of their vocabulary.

These new guidelines state that if a person has confirmation that the mother consumed alcohol during the pregnancy, and shows three impairments in the areas of brain development, motor skills or movement, cognition or general thinking, language, academics or school grades, memory, attention, executive functioning which is basically planning and organization skills, mental health and social ability, they can be diagnosed with FASD.  If the child shows from baby pictures they had narrow eyes, a flat ridge below their nose and a thin upper lip, they are diagnosed with FASD with sentinel features.  If they are missing one of those three physical features, then it is without sentinel features.  The new guidelines eliminated pFAS, FAS and ARND as diagnosis terms and it is simply called FASD now.  It also added mental health as a new impairment and eliminated growth rate.  It establishes that a psychologist, speech-language pathologist, and occupational therapist assessments are needed to determine if three of the ten domains exist.  It then requires a medical practitioner familiar with FASD characteristics to make the diagnosis.  It strongly encourages using the multi-disciplinary model to properly diagnosis and support the person impacted by FASD.

You should also be aware of practices to avoid.  Because these are only guidelines, any medical practitioner can diagnose. Within our current medical culture, there is controversy and disagreement as to how this condition should be diagnosed.  The DSM-5 which establishes the guidelines for psychologists also give them the ability to diagnose neurobehavioral disorder associated with prenatal alcohol exposure under which FASD does fall.  However, a recent study published by the same CMA Journal, shows the DSM-5 guidelines only captures about half of the FASD diagnoses these new guidelines diagnose. http://cmajopen.ca/content/5/1/E178.full  The importance of using a multi-disciplinary approach to diagnose is incredibly important.  Because multidisciplinary teams can be rare depending on where you are located, you may need to become your own team.  This situation existed for us.  When we suspected our children had FASD, we got the diagnosis and support as soon as possible.  First, we went to a pediatrician who understands what FASD is.  Next, we got any type of documentation that stated there was a strong possibility that the mother may have drank during the pregnancy.  In our case, it was a CAS social worker who gave us a letter making that statement and who gave us frontal head shot photos from age six months to 6 years.  At age 3-4, we got a speech-language assessment with occupational therapy recommended.  At age 4-5, we got the occupational therapy assessment with a sensory profile as well.  With this, we started working with the school and got a special education plan and keep copies of all their documentation.  In grade 3, we got a neuro psychological assessment.  A psychological educational assessment will also work.  With all this documentation, we went to our pediatrician and ask for the referral to an appropriate medical practitioner. 

While there isn’t any realistic cure for FASD right now, early intervention is important.  A common story today is people impacted by FASD getting diagnosed when things get bad.  This may include attempting suicide, getting arrested, employment challenges, gang participation or being in abusive relationships.  These are common outcomes when the individuals aren’t being provided the necessary supports with established routines.  When you have early intervention, you are no longer guessing why these individuals are behaving in the way they are.  You can start teaching coping strategies, discovering triggers, implementing supports, and establish relationships at a time when the child will be receptive to receiving them.  If you are trying to establish these things with an adult, you are now dealing with low self-esteem, distrust, depression and shame at the same time.

One exciting new development in this area was recently announced by UBC genetic researchers.  They have discovered that people impacted by FASD have DNA with unusual methylation. Basically, their DNA doesn’t work properly.  However, there are several conditions that can have this unusual type of DNA so they can’t use it yet for early detection.  Other researchers have been able to identify certain DNA patterns that normally means a likelihood to develop certain types of cancer.  It is the hope they will be able to do the same for FASD.  Research is also showing healthy living makes a huge impact as well.  Eating right, sleeping well, getting lots of exercise and having the right vitamins such as iron will enable the person to manage the other aspects of their lives much more effectively.

As to treatment, the objective is to manage the condition.  Because the condition is a spectrum disorder, each individual need supports particular to them.  While medication seems to have widely varying effects, proper counseling should certainly be used.  Cognitive Behaviour Therapy should be avoided, though, because it only increase shame.  Self-awareness is a powerful tool for the individual because most of the time they are aware of how they are coping.  They just can’t do anything about it on their own.  Knowing what they are good at, being able to advocate for themselves, understanding what their triggers are and how to cope with them, discovering what their best methods of learning are and realizing and accepting support in their areas of need are all necessary components for success.  They may need people like a financial trustee, a system navigator, a house cleaner, an understanding employer, a supportive church and a close group of friends watching out for them.  While it is currently rare to meet an adult impacted by FASD to have received early intervention and current supports, when you do meet one, you will see them living interdependent and fulfilling lives. 

You may hear people talk about potential treatments like neurogenesis treatments and neuroplasticity.  I would strongly caution you about these treatments.  The basis of these treatments is to take the brain back to an earlier state.  It works for stroke victims because they had a properly working brain earlier.  However, with FASD, there was never an earlier properly working brain. 

FASD is not to be feared.  I see daily that within my family and other local families that individuals impacted by FASD can be happy, successful and interdependent.  With awareness, advocacy, education, support, healthy living and faith, there is hope.

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