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Ask the Mental Health Expert Archives 2001-2004

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FAS in Young Adulthood

Q. I am working with a young adult male with developmental disabilities and characteristics of fetal alcohol syndrome. He has lived in a adult foster care setting with shift staff and three other individuals for the past six years. Learning through trial and error, a structured program has been developed of monetary rewards and lost privileges as consequences. He lately has had more episodes of drinking behavior. I worry that the consequences have lost power to changes his behavior. I intend to go back to more structure and a tighter program because of these resent episodes. Do you recommend any treatment approaches that might be helpful in assisting a person with FAS not to abuse alcohol? Is this just going to be his pattern in life--tight structure, more choices and freedoms, drinking behavior and back to tight structure?

A. I can't give you specific advice on the prognosis or treatment of this individual, since I haven't evaluated him. However, I am not aware of any special factors that would shape treatment recommendations for an individual with FAS, as opposed to anyone else with a substance abuse disorder. Rather, the issue would be, to what extent do the patient's cognitive abilities or disabilities restrict the range of available treatments?

For example, you have used a primarily behavioral approach with some success, until recently. Perhaps adding a more cognitive component could be helpful, possibly in combination with a medication like naltrexone (ReVia). A study by Dr. Raymond Anton and colleagues, published in the November 1999 American Journal of Psychiatry, found that a combination of naltrexone and cognitive-behavioral therapy (CBT) was effective in reducing relapse among heavy drinkers. Antabuse might also be an option worth considering, if the patient is willing and able to consent. Also, you did not mention whether this client has been involved in a 12-step program, such as AA.

Even though the patient may have some developmentally-based cognitive disabilities, I would not rule out the usefulness of such 12-step organizations. Some particularly refractory patients may need random urine checks, as another component of their treatment. For more information on options, try the Substance Abuse and Mental Health Administration website (http://www.samhsa.gov).

Finally, I wonder why there has been this worsening in the young man's drinking behavior? Could there be a new psychiatric problem, such as a superimposed depressive episode, or an undiagnosed anxiety disorder? Are there some new psychosocial stressors that might be setting off the increased drinking? I would certainly recommend a full psychiatric evaluation by a psychiatrist with expertise in substance abuse treatment and dual diagnosis patients. This might lead to a trial on an antidepressant, anxiolytic, or even a mood-stabilizer. For some dual-diagnosis patients, these medications can be helpful in reducing substance abuse. Getting a consultation from a behavioral psychologist might also be a useful approach, even if this happens to be your own background. Sometimes a fresh look by a colleague can be very helpful. Good luck.

August 2001

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