1. Working with High Risk Women and Children An Integrated Mother-Child Perspective on FASD Margaret Leslie Dip.C.S., C.Psych.Assoc. Director, Early Intervention Programs Mothercraft/Breaking the Cycle

2. BTC PARTNERS Mothercraft Jean Tweed Centre MotheRisk - Hospital for Sick Children Children’s Aid Society of Toronto Toronto Public Health Catholic Children’s Aid Society of Toronto St. Joseph’s Health Centre

4. THE SUSAN STORY

5. FAMILY HISTORY BTC mothers reported the following: 51% of their mothers had/have substance use problems 65% of their fathers had/have substance use problems 81% were physical abused -- the perpetrator was most likely their mother or their father’s/mother’s partner 83% experienced emotional abuse -- most likely by their mother, or their father’s/mother’s partner 67% experienced sexual abuse -- almost 30% of the perpetrators were family members

6. SUBSTANCE USE HISTORY BTC mothers reported their average age of first use: Nicotineaged 13.1 Inhalantsaged 13.1 Alcoholaged 14 Cannabisaged 15.8 Hallucinogensaged 15.8 Amphetaminesaged 16.8 Barbituates/sleeping pillsaged 18.2 Cocaineaged 19.4 Tranquilizersaged 20 Crack cocaineaged 21.5 Heroinaged 21.8 Antidepressantsaged 26.3 Over the counter drugsaged 26.4

7. EATING DISORDERS Eating disorders were a problem for 40% of BTC mothers. Of these, 47% indicated that their eating disorders were active and ongoing 33% reported that they were bulimic 29% reported that they were compulsive overeaters 16% reported multiple eating disorders 16% reported that they were anorexic

8. SELF-HARM BEHAVIOURS 26% of BTC mothers reported that they currently engage in self-harm behaviours, or have engaged in self-harm behaviours in the past

9. PARTNER ABUSE 82% of BTC mothers reported a history of physical abuse 43% of BTC mothers reported that their partners are physically abusive 29% of BTC mothers reported that their partners are emotionally abusive 72% of mothers reported that their partners are substance users 60.4% of mothers reported that they had good/supportive relationships with their partners, but these same partners were responsible for 40% of the physical abuse and 29% of the emotional abuse

10. EMOTIONAL/ PSYCHOLOGICAL PROBLEMS BTC mothers reported experiencing the following symptoms in the six- month period prior to intake: 87%tension, anxiety or nervousness 76%depression 48.9%fear or phobias 42%amnesia 34%experienced thoughts that someone was trying to harm them 73%sleeping pattern disturbances 67%eating pattern disturbances 35%violent thoughts or feelings 35%thoughts of suicide 21%other emotional/psychological problems 43%currently experiencing flashbacks 43% of mothers reported that they had attempted suicide

11. TREATMENT HISTORY The majority of BTC mothers (82%)have had previous treatment experience. Of these, 49% had been treated in a residential program 47% reported previous self-help treatment 41.4% had been treated at detoxification centres 28% had attended day programs 35% were previously involved in addiction counselling 11% had used a hospital treatment program and 9% had been treated with Antabuse/Temposil

12. POVERTY The yearly income reported by BTC mothers is: 44.3%Less than $9,999 38.3%10,000-14,999 4.9%15,000-19,999 4.9%20,000-29,999 2.2%30,000-39,999 2.7%40,000-49,999 2.7%50,000 or more

13. 51% of mothers reported that their mothers misused substances (Pepler et al, 2003) More than one-third reported that their mothers had problems with alcohol (Rouleau et al, 2004) When compared to the general population, BTC mothers had higher rates of learning disabilities, criminality, depression, suicide attempts and low levels of educational attainment Mothers reported their prenatal substance use history accurately and completely (Avner et al 2004) At Breaking the Cycle…..

14. Prevention of the primary disability - FASD 1.Universal Prevention (directed to the general public) Public awareness campaigns Alcohol control policies (incl. increased taxation, responsible service) Beverage warning labels 2.Selective Prevention (directed to women of childbearing age who consume alcohol) Screening (T-ACE, TWEAK) Referral Brief interventions

15. Prevention of the primary disability - FASD 3.Indicated Prevention (aimed at pregnant women who have significant alcohol use problems) through: Access to comprehensive, respectful, flexible and integrated programs, designed to prevent or reduce harms associated with alcohol or other substance use in pregnancy Attention to the social and economic conditions which influence prenatal alcohol use, incl. –Housing stability –Income stability –Food security –Access to primary health care –Access to prenatal care –Access to women-centred addiction treatment programs –Supportive personal relationships free from violence –Social inclusion

16. Prevention of secondary disabilities Mental health problemsAlcohol/drug problems Disrupted school experienceTrouble with the law Inappropriate sexual behaviourConfinement Problems with employmentDependent living Unplanned pregnancies…. Streissguth et al,1996

17. Protective factors for secondary disabilities Living in a stable and nurturant home for over 72% of life Being diagnosed before the age of 6 years Never having experienced violence against oneself Staying in each living situation for an average of more than 2.8 years Experiencing a good quality home from 8-12 years Having applied for and been found eligible for Division of Developmental Disabilities Having basic needs met for at least 13% of life Having a diagnosis of FAS (vs. FAE) Streissguth et al,1996

18. Prevention of secondary disabilities -- the importance of diagnosis Assessment and diagnosis requires a multi-disciplinary approach which integrates prenatal history with the medico- physical and neurodevelopmental/behavioural functioning of the child Confirmation of prenatal maternal alcohol use is required for diagnosis Diagnosis before age 6 years is a salient protective factor against the development of secondary disabilities Diagnosis provides a blueprint for intervention

19. Components of successful approaches Collaborative relationships and agreements with other services and systems (addictions treatment, child welfare, health/medical, mental health, employment, corrections, justice, housing/shelter, early childhood intervention, children’s mental health) Outreach to facilitate engagement of women and children into comprehensive programs Acknowledgement and attention to the context of women’s substance use in pregnancy and while parenting Culturally competent programming Acceptance of harm reduction goals Use of motivational interviewing strategies Comprehensive, intensive, coordinated care that is multidisciplinary and integrates maternal and child services, and is offered through a single access point Roberts & Nanson (2002) Best Practices: FAS/FAE and the Effects of Other Substance Use Suring Pregnancy. Ottawa:Health Canada United Nations Office on Drugs and Crime (2004). Substance Abuse Treatment and Care for Women: Case Studies and Lessons Learned. Vienna: United Nations

20. Intervention…… Through practice modifications SafetyCaringDependability/reliability StabilityPredictabilityAdvocacy/case management StructureResponsivity/congruenceEnvironmental adaptations HealthJustice/CorrectionsChildren’s Services Mental HealthEducationIncome Support EducationHousing/Shelter Through policy integration Intergovernmental Cross-departmental