alcoholism case study examples

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

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Robert’s story

Robert was living with an alcohol addiction and was homeless for over 25 years. He was well known in the local community and was identified as one of the top 100 A&E attendees at the Local General Hospital.

He drank all day every day until he would pass out and this was either in the town centre or just by the roadside. In addition, Robert was also incontinent and really struggled with any meaningful communication or positive decision making due to his alcohol usage. This often resulted in local services such as police, ambulance being called in to help. He had no independent living skills and was unable to function without alcohol.

In addition, and due to his lifestyle and presenting behaviours, Robert had a hostile relationship with his family and had become estranged from them for a long period of time.

Robert needed ongoing support and it was identified at the General Hospital that if he was to carry on “living” the way he currently was, then he wouldn’t survive another winter.

On the back of this, Robert was referred to Calico who organised a multi-disciplinary support package for him, which included support with housing as part of the Making Every Adult Matter programme.

After some initial challenges, Robert soon started to make some positive changes.

The intensive, multidisciplinary support package taught him new skills to support him to live independently, sustain his tenancy and make some positive lifestyle changes which in turn would improve his health and wellbeing.

This included providing daily visits in the morning to see Robert and to support him with some basic activities on a daily/weekly basis. This included getting up and dressed; support with shopping and taking to appointments; guidance to help make positive decisions around his associates; support about his benefits and managing his money. In addition, he was given critical support via accessing local groups such as RAMP (reduction and motivational programme) and Acorn (drugs and alcohol service), as well as 1 to 1 sessions with drugs workers and counsellors to address his alcohol addiction.

After six months Robert continued to do well and was leading a more positive lifestyle where he had greatly reduced his A&E attendance. He had significantly reduced his alcohol intake with long periods of abstinence and was now able to communicate and make positive decisions around his lifestyle.

Critically he had maintained his tenancy and continued to regularly attend local groups and other support for his alcohol addiction and had reconnected with some of his family members.

By being able to access these community resources and reduce his isolation he is now engaged in meaningful activities throughout the day and has been able to address some of his critical issues. A small but significant example is that Robert is now wearing his hearing aids which means that he can now interact and communicate more effectively.

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Jo-Hanna Ivers 1* and Kevin Ducray 2

In October 2012, 83 front-line Irish service providers working in the addiction treatment field received accreditation as trained practitioners in the delivery of a number of evidence-based positive reinforcement approaches that address substance use: 52 received accreditation in the Community Reinforcement Approach (CRA), 19 in the Adolescent Community Reinforcement Approach (ACRA) and 12 in Community Reinforcement and Family Training (CRAFT). This case study presents the treatment of a 17-year-old white male engaging in high-risk substance use. He presented for treatment as part of a court order. Treatment of the substance use involved 20 treatment sessions and was conducted per Adolescent Community Reinforcement Approach (A-CRA). This was a pilot of A-CRA a promising treatment approach adapted from the United States that had never been tried in an Irish context. A post-treatment assessment at 12-week follow-up revealed significant improvements. At both assessment and following treatment, clinician severity ratings on the Maudsley Addiction Profile (MAP) and the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) found decreased score for substance use was the most clinically relevant and suggests that he had made significant changes. Also his MAP scores for parental conflict and drug dealing suggest that he had made significant changes in the relevant domains of personal and social functioning as well as in diminished engagement in criminal behaviour. Results from this case study were quite promising and suggested that A-CRA was culturally sensitive and applicable in an Irish context.

1. Theoretical and Research Basis for Treatment

Substance use disorders (SUDs) are distinct conditions characterized by recurrent maladaptive use of psychoactive substances associated with significant distress. These disorders are highly common with lifetime rates of substance use or dependence estimated at over 30% for alcohol and over 10% for other substances [1 , 2] . Changing substance use patterns and evolving psychosocial and pharmacologic treatments modalities have necessitated the need to substantiate both the efficacy and cost effectiveness of these interventions.

Evidence for the clinical application of cognitive behavioural therapy (CBT) for substance use disorders has grown significantly [3 - 8] . Moreover, CBT for substance use disorders has demonstrated efficacy both as a monotherapy and as part of combination treatment [7] . CBT is a time-limited, problem-focused, intervention that seeks to reduce emotional distress through the modification of maladaptive beliefs, assumptions, attitudes, and behaviours [9] . The underlying assumption of CBT is that learning processes play an imperative function in the development and maintenance of substance misuse. These same learning processes can be used to help patients modify and reduce their drug use [3] .

Drug misuse is viewed by CBT practitioners as learned behaviours acquired through experience [10] . If an individual uses alcohol or a substance to elicit (positively or negatively reinforced) desired states (e.g. euphorigenic, soothing, calming, tension reducing) on a recurrent basis, it may become the preferred way of achieving those effects, particularly in the absence of alternative ways of attaining those desired results. A primary task of treatment for problem substance users is to (1) identify the specific needs that alcohol and substances are being used to meet and (2) develop and reinforce skills that provide alternative ways of meeting those needs [10 , 11] .

CRA is a broad-spectrum cognitive behavioural programme for treating substance use and related problems by identifying the specific needs that alcohol and or other substances are satisfying or meeting. The goal is then to develop and reinforce skills that provide alternative ways of meeting those needs. Consistent with traditional CBT, CRA through exploration, allows the patient to identify negative thoughts, behaviours and beliefs that maintain addiction. By getting the patient to identify, positive non-drug using behaviours, interests, and activities, CRA attempts to provide alternatives to drug use. As therapy progresses the objective is to prevent relapse, increase wellness, and develop skills to promote and sustain well-being. The ultimate aim of CRA, as with CBT is to assist the patient to master a specific set of skills necessary to achieve their goals. Treatment is not complete until those skills are mastered and a reasonable degree of progress has been made toward attaining identified therapy goals. CRA sessions are highly collaborative, requiring the patient to engage in ‘between session tasks’ or homework designed reinforce learning, improve coping skills and enhance self efficacy in relevant domains.

The use of the Community Reinforcement Approach is empirically supported with inpatients [12 , 13] , outpatients [14 - 16] and homeless populations (Smith et al., 1998). In addition, three recent metaanalytic reviews cited CRA as one of the most cost-effective treatment programmes currently available [17 , 18] .

A-CRA is a evidenced based behavioural intervention that is an adapted version of the adult CRA programme [19] . Garner et al [19] modified several of the CRA procedures and accompanying treatment resources to make them more developmentally appropriate for adolescents. The main distinguishing aspect of A-CRA is that it involves caregivers—namely parents or guardians who are ultimately responsible for the adolescent and with whom the adolescent is living.

A-CRA has been tested and found effective in the context of outpatient continuing care following residential treatment [20 - 22] and without the caregiver components as an intervention for drug using, homeless adolescents [23] . More recently, Garner et al [19] collected data from 399 adolescents who participated in one of four randomly controlled trials of the A-CRA intervention, the purpose of which was to examine the extent to which exposure to A-CRA procedures mediated the relationship between treatment retention and outcomes. The authors found adolescents who were exposed to 12 or more A-CRA procedures were significantly more likely to be in recovery at follow-up.

Combining A-CRA with relapse prevention strategies receives strong support as an evidence based, best practice model and is widely employed in addiction treatment programmes. Providing a CBT-ACRA therapeutic approach is imperative as it develops alternative ways of meeting needs and thus altering dependence.

2. Case Introduction

Alan is a 17 year-old male currently living in County Dublin. Alan presented to the agency involuntarily and as a requisite of his Juvenile Liaison Officer who was seeing him on foot of prior drugs arrest for ‘possession with intent to supply’; a more serious charge than a simple ‘drugs possession’ charge. As Alan had no previous charges he was placed on probation for one year. This was Alan’s first contact with the treatment services. A diagnostic assessment was completed upon entry to treatment and included completion of a battery of instruments comprising the Maudsley Addiction Profile (MAP), The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Beck Youth Inventory (BYI) (see appendices for full description of outcome measures) (Table 1).

3. Diagnostic Criteria

The apparent symptoms of substance dependency were: (1) Loss of Control - Alan had made several attempts at controlling the amounts of cannabis he consumed, but those times when he was able to abstain from cannabis use were when he substituted alcohol and/or other drugs. (2) Family History of Alcohol/Drug Usage - Alan’s eldest sister who is now 23 years old is in recovery from opiate abuse. She was a chronic heroin user during her early adult years [17 - 21] . During this period, which corresponds to Alan’s early adolescent years [12 - 15] she lived in the family home (3) Changes in Tolerance - Alan began per day. At presentation he was smoking six to eight cannabis joints daily through the week, and eight to twelve joints daily on weekends.

4. Psychosocial, Medical and Family History

At time of intake Alan was living with both of his parents and a sister, two years his senior, in the family home. Alan was the youngest and the only boy in his family. He had two other older sisters, 5 and 7 years his senior. He was enrolled in his 5th year of secondary school but at the time of assessment was expelled from all classes. Alan had superior sporting abilities. He played for the junior team of a first division football team and had the prospect of a professional career in football. He reported a family history positive for substance use disorders. An older sister was in recovery for opiate dependence. Apart from his substance use Alan reported no significant psychological difficulties or medical problems. His motives for substance use were cited as boredom, curiosity, peer pressure, and pleasure seeking. His triggers for use were relationship difficulties at home, boredom and peer pressure. Pre-morbid personality traits included thrill seeking and impulsivity (Table 2).

5. Case Conceptualisation

A CBT case formulation is based on the cognitive model, which hypothesizes that "a person’s feelings and emotions are influenced by their perception of events" . It is not the actual event that determines how the person feels, but rather how they construe the event (Beck, 1995 p14). Moreover, cognitive theory posits that the “child learns to construe reality through his or her early experiences with the environment, especially with significant others” and that “sometimes these early experiences lead children to accept attitudes and beliefs that will later prove maladaptive” [24] . A CBT formulation (or case conceptualisation) is one of the key underpinnings of Cognitive Behavioural Therapy (CBT). It is the ‘blueprint’ which aids the therapist to understand and explain the patient’s’ problems.

Formulation driven CBT enables the therapist to develop an individualised understanding of the patient and can help to predict the difficulties that a patient may encounter during therapy. In Alan’s case, exploring his existing negative automatic thoughts about regarding school and his academic competences highlighted the difficulties he could experience with CBT homework completion. Whilst Alan was good at between session therapy assignments, an exploration of what is meant by ‘homework’ in a CBT context was crucial.

A collaborative CBT formulation was done diagrammatically together with Alan (Figure 1). This formulation aimed to describe his presenting problems and using CBT theory, to explore explanatory inferences about the initiating and maintaining factors of his drug use which could practically inform meaningful interventions.

Simmons and Griffiths et al. make the insightful observation that particular group differences need to be specifically considered and suggest that the therapist should be cognizant of the role of both society and culture when developing a formulation. They firstly suggest that the impact played by gender, sexuality and socio-cultural roles in the genesis of a psychological disorder, namely the contribution that being a member of a group may have on predisposing and precipitating factors, be carefully considered. An example they offer is the role of poverty on the development of psychological problems, such as the link evidenced between socio economic group and onset of schizophrenia. This was clearly evident in the case of Alan, who being a member of a deprived socioeconomic group, growing up and living in an area with a high level of economic deprivation, perceived that his choices for success were limited. His thinking, as an adolescent boy, was dichotomous in that he saw himself as having only two fixed and limited choices (a) being good at sport he either pursue a career as a professional sportsman or alternatively (b) he engage in crime and work his way up through the ranks as a ‘career criminal’. Simmons & Griffiths secondly suggest that being a member of a particular group can heavily influence a person’s understanding of the causality of their psychological disorder. A third consideration when developing a formulation is the degree to which being a member of a particular group may influence the acceptance or rejection of a member experiencing a psychological illness. Again this is pertinent in Alan’s case as he was part of a sub-group, a gang engaged in crime. For this cohort, crime and drug use were synonymous. Using drugs was viewed as a rite of passage for Alan.

Drug use, according to CBT models, are socially learned behaviours initiated, maintained and altered through the dynamic interaction of triggers, cues, reinforcers, cognitions and environmental factors. The application of a such a formulation, sensitive to Simmons and Griffiths (2009) aforementioned observations, proved useful in affording insights into the contextual and maintaining factors of Alan’s drug use which was heavily influenced by the availability of drugs ,his peer group (with whom he spent long periods of time) and their petty drug dealing and criminality. Similarly, engaging with his football team mates during the lead up to an important match significantly reduced his drug use and at certain times of the year even lead to abstinence. Sharing this formulation allowed him to note how his drug use patterns were driven, as per the CBT paradigm, by modifiable external, transient, and specific factors (e.g. cues, reinforcements, social networks and related expectations and social pressures).

Employing the A-CRA model allowed for this tailored fit as A-CRA specifically encourages the patient to identify their own need and desire for change. Alan identified the specific needs that were met by using substances and he developed and reinforced skills that provided him with alternative ways of meeting those needs. This model worked extremely well for Alan as he had identified and had ready access to a pro- social ‘alternative group’ or community. As he had had access to an alternative positive peer group and another activity (sport) which he was ‘really good at’, he simply needed to see the evidence of how his context could radically affect his substance use; more specifically how his beliefs, thinking and actions in certain circumstances produced very different drug use consequences and outcomes.

6. Course of Treatment and Assessment of Progress

One focus of CBT treatment is on teaching and practising specific helpful behaviours, whilst trying to limit cognitive demands on clients. Repetition is central to the learning process in order to develop proficiency and to ensure that newly acquired behaviours will be available when needed. Therefore, behavioural using rehearsal will emphasize varied, realistic case examples to enhance generalization to real life settings. During practice periods and exercises, patients are asked to identify signals that indicate high-risk situations, demonstrating their understanding of when to use newly acquired coping skills. CBT is designed to remedy possible deficits in coping skills by better managing those identified antecedents to substance use. Individuals who rely primarily on substances to cope have little choice but to resort to substance use when the need to cope arises. Understanding, anticipating and avoiding high risk drug use scenarios or the “early warning signals” of imminent drug use is a key CBT clinical activity.

A major goal of a CBT/A-CRA therapeutic approach is to provide a range of basic alternative skills to cope with situations that might otherwise lead to substance use. As ‘skill deficits’ are viewed as fundamental to the drug use trajectory or relapse process, an emphasis is placed on the development and practice of coping skills. A-CRA was manualised in 2001 as part of the Cannabis Youth Treatment Series (CYT) and was tested in that study [21] and more recently with homeless youth [23] . It was also adapted for use in a manual for Assertive Continuing Care following residential treatment [20] .

There are twelve standard and three optional procedures proposed in the A-CRA model. The delivery of the intervention is flexible and based on individual adolescent needs, though the manual provides some general guidelines regarding the general order of procedures. Optional procedures are ‘Dealing with Failure to Attend’, ‘Job-Seeking Skills’, and ‘Anger Management’. Standard procedures are included in table 3 below. For a more detailed description of sessions and procedures please see appendices.

Smith and Myers describe the theoretical underpinnings of CRA as a comprehensive behavioural program for treating substance-abuse problems. It is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging drinking or drug use. Consequently, it utilizes social, recreational, familial, and vocational reinforcers to assist consumers in the recovery process. Its goal is to essentially make a sober lifestyle more rewarding than the use of substances. Interestingly the authors note: ‘Oddly enough, however, while virtually every review of alcohol and drug treatment outcome research lists CRA among approaches with the strongest scientific evidence of efficacy, very few clinicians who treat consumers with addictions are familiar with it’. ‘The overall philosophy is to promote community based rewarding of non drug-using behaviour so that the patient makes healthy lifestyle changes’ p.3 [25] .

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment. This tailored approach is facilitated by conducting a ‘functional analysis’ of the adolescent’s behaviour at the beginning of therapy so they can better understand and interrupt the links in the behavioural chain typically leading to episodes of drug use. A-CRA therapists then teach individuals how to improve communication and other skills, build on their reinforcers for abstinence and use existing community resources that will support positive change and constructive support systems.

A-CRA emphasises lapse and relapse prevention. Relapseprevention cognitive behavioural therapy (RP-CBT) is derived from a cognitive model of drug misuse. The emphasis is on identifying and modifying irrational thoughts, managing negative mood and intervening after a lapse to prevent a full-blown relapse [26] . The emphasis is on development of skills to (a) recognize High Risk Situations (HRS) or states where clients are most vulnerable to drug use, (b) avoidance of HRS, and (C) to use a variety of cognitive and behavioural strategies to cope effectively with these situations. RPCBT differs from typical CBT in that the accent is on training people who misuse drugs to develop skills to identify and anticipate situations or states where they are most vulnerable to drug use and to use a range of cognitive and behavioural strategies to cope effectively with these situations [26] .

7. Access and Barriers to Care

Alan engaged with the service for eight months. During this time he received twenty sessions, three of which were assessment focused, the remaining seventeen sessions were A-CRA focused; two of the seventeen involved his mother, the remaining fifteen were individual. As Alan was referred by the probation services, he was initially somewhat ambivalent about drug use focussed interventions. His early motivation for engagement was primarily to avoid the possibility of a custodial sentence.

8. Treatment

My sessions with Alan were guided by the principles of A-CRA [27] which focuses on coping skills training and relapse prevention approaches to the treatment of addictive disorders. Prior to engaging with Alan, I had completed the training course and commenced the A-CRA accreditation process, both under the stewardship of Dr Bob Meyers, whose training and publication offers detailed guidelines on skills training and relapse prevention with young people in a similar context [27] .

During the early part of each session I focused on getting a clear understanding of Alan’s current concerns, his general level of functioning, his substance abuse and pattern of craving during the past week. His experiences with therapy homework, the primary focus being on what insight he gained by completing such exercises was also explored. I spent considerable time engaged in a detailed review of Alan’s experience with the implementation of homework tasks during which the following themes were reviewed:

-Gauging whether drug use cessation was easier or harder than he anticipated? -Which, if any, of the coping strategies worked best? -Which strategies did not work as well as expected. Did he develop any new strategies? -Conveying the importance of skills practice, emphasising how we both gained greater insights into how cognitions influenced his behaviour. After developing a clear sense of Alan’s general functioning, current concerns and progress with homework implementation, I initiated the session topic for that week. I linked the relevance of the session topic to Alan’s current cannabis-related concerns and introduced the topic by using concrete examples from Alan’s recent experience. While reviewing the material, I repeatedly ensured that Alan understood the topic by asking for concrete examples, while also eliciting Alan’s views on how he might use these particular skills in the future.

Godley & Meyers [21] propose a homework exercise to accompany each session. An advantage of using these homework sheets is that they also summarise key points about each topic and therefore serve as a useful reminder to the patient of the material discussed each week. Meyers, et al. (2011) suggests that rather than being bound by the suggested exercises in the manualised approach, they may be used as a starting point for discussing the best way to implement the required skill and to develop individualised variations for new assignments [27] . The final part of each session focused on Alan’s plan for the week ahead and any anticipated high-risk situations. I endeavoured to model the idea that patients can literally ‘plan themselves out of using’ cannabis or other drugs. For each anticipated high-risk situation, we identified appropriate and viable coping skills. Better understanding, anticipating and planning for high-risk situations was difficult in the beginning of treatment as Alan was not particularly used to planning or thinking through his activities. For a patient like Alan, whose home life is often chaotic, this helped promote a growing sense of self efficacy. Similarly, as Alan had been heavily involved with drug use for a long time, he discovered through this process that he had few meaningful activities to fill his time or serve as alternatives to drug use. This provided me with an opportunity to discuss strategies to rebuild an activity schedule and a social network.

During our sessions, several skill topics were covered. I carefully selected skills to match Alan’s needs. I selected coping skills that he has used in the past and introduced one or two more that were consistent with his cognitive style. Alan’s cognitive score indicated a cognitive approach reflecting poor problem solving or planning. Sessions focused on generic skills including interpersonal skills, goal setting, coping with criticism or anger, problem solving and planning. The goal was to teach Alan how to build on his pro- social reinforcers, how to use existing community resources supportive of positive change and how to develop a positive support system.

The sequence in which these topics were presented was based on (a) patient needs and (b) clinician judgment (a full description of individual sessions may be found in appendices).

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment.

9. Assessment of Treatment Outcome

A baseline diagnostic assessment of outcomes was completed upon treatment entry. This assessment consisted of a battery of psychological instruments including (see appendices for full a description of assessment measures):

-The Maudsley Addiction Profile (MAP). -The Beck Youth Inventories. -The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

In addition to the above, objective feedback on Alan’s clinical and drug use status through urine toxicology screens was an important part of his drug treatment. Urine specimens were collected before each session and available for the following session. The use of toxicology reports throughout treatment are considered a valuable clinical tool. This part of the session presents a good opportunity to review the results of the most recent urine toxicology screen and promote meaningful therapeutic activities in the context of the patient’s treatment goals [28] .

In reporting on substance use since the last session, patients are likely to reveal a great deal about their general level of functioning and the types of issues and problems of most current concern. This allows the clinician to gauge if the patient has made progress in reducing drug use, his current level of motivation, whether there is a reasonable level of support available in efforts to remain abstinent and what is currently bothering him. Functional analyses are opportunistically used throughout treatment as needed. For example, if cannabis use occurs, patients are encouraged to analyse antecedent events so as to determine how to avoid using in similar situations in the future. The purpose is to help the patient understand the trajectory and modifiable contextual factors associated with drug use, challenge unhelpful positive drug use expectancies, identify possible skills deficiencies as well as seeking functionally equivalent non- drug using behaviours so as to reduce the probability of future drug use. The approach I used is based on the work of [28] .

The Functional Analysis was used to identify a number of factors occurring within a relatively brief time frame that influenced the occurrence of problem behaviours. It was used as an initial screening tool as part of a comprehensive functional assessment or analysis of problem behaviour. The results of the functional analysis then served as a basis for conducting direct observations in a number of different contexts to attest to likely behavioural functions, clarify ambiguous functions, and identify other relevant factors that are maintaining the behaviour.

The Happiness Scale rates the adolescent’s feelings about several critical areas of life. It helps therapists and adolescents identify areas of life that adolescents feel happy about and alternatively areas in which they have problems or challenges. Most importantly it identifies potential treatment goals subjectively meaningful to the patient, facilitates positive behaviour change in a range of life domains as well as help clients track their progress during treatment.

Alan’s BYI score (Table 4) indicates that at the time of assessment he was within the average scoring range on ‘self-concept’, and moderately elevated in the areas of ‘depression’, ‘anxiety’, and ‘disruptive behaviour’. His score for ‘anger’ suggested that his anger fell within the extremely elevated range. When this was discussed with Alan he agreed that this was quite accurate. Anger, and in particular controlling his anger, was subjectively identified as a treatment goal.

10. Follow-up

Given that follow-up occurred by telephone it was not feasible to administer the full battery of tests. With Alan’s treatment goals in mind it was decided to administer the MAP and ASSIST. Table 5 below illustrates Alan’s score at baseline and follow-up for the MAP and ASSIST. For summary purposes I have taken areas for concern at baseline for both instruments.

Alan’s score for cannabis was the most clinically relevant as it placed him in the 'high risk’ domain while his alcohol score indicated that he had engaged in binge drinking (6+ drinks) at T1. However, at T2 Alan’s score suggests that he had made considerable reductions in the use of both substances. Also his MAP scores for parental conflict and drug dealing suggest that he had also made major positive changes in the relevant domains of personal and social functioning as well as ceasing criminal behaviour.

At 3 months post-discharge I contacted Alan by phone. He had maintained and continued to further his progress. His drug use was at a minimal level (1 or 2 shared joints per month). He was no longer engaged in crime and his probationary period with the judicial system had passed. He had received a caution for his earlier drugs charge. At the time of follow-up he was enjoying participating in a Sports Coaching course and was excelling with his study assignments. Relationships had improved considerably with his mother and sister and he had re-engaged with a previous, positive, peer group linked to his involvement with the GAA . Overall he felt he was doing extremely well.

11. Complicating Factors with A-CRA Model

There are many challenges that may arise in the treatment of substance use disorders that can serve as barriers to successful treatment. These include acute or chronic cognitive deficits, health problems, social stressors and a lack of social resources [7] . Among individuals presenting with substance use there are often other significant life challenges including early school leaving, family conflicts, legal issues, poor or deviant social networks, etc. A particular challenge with Alan’s case was the social and environmental milieu which he shared with his drug using peers. For Alan, who initially had few skills and resources, engaging in treatment meant not only being asked to change his overall way of life but also to renounce some of those components in which he enjoyed a sense of belonging, particularly as he had invested significantly in these friendships. A sense of ‘belonging to the substance use culture’ can increase ambivalence for change [7] . Alan’s mother strongly disapproved of his drug using peer group and failed to acknowledge Alan’s perceived loss. This resulted in mother- son conflict. The use of the caregiver session allowed an exploration of perceived ‘losses’ relative to the ‘gains’ associated with Alan’s abstinence. It was moreover seen to be critical to establish alternatives for achieving a sense of belonging, including both his social connection and his social effectiveness. Alan’s sports ability allowed for this to be fostered. He is a talented sportsman which often meant his acceptance within a team or group is a given.

Despite the positive effects of A-CRA it is not without its shortcomings. The approach is at times quite American- oriented, particularly around identifying local resources and its focus on culturally specific outlets in promoting social engagement as alternatives to substance use. While this is supported in the literature, it may not necessarily be transferable to certain Irish adolescent contexts or subcultures.

12. Treatment Implications of the Case

A-CRA captures a broad range of behavioural treatments including those targeting operant learning processes, motivational barriers to improvement and other more traditional elements of cognitivebehavioural interventions. Overall, this intervention has demonstrated efficacy. Despite this heterogeneity, core elements emerge based in a conceptual model of SUDs as disorders characterized by learning processes and driven by the strongly reinforcing effects of the substances of abuse. There is rich evidence in the substance use disorders literature that improvement achieved by CBT (7) and indeed A-CRA (Godley et al. and Garner et al. [22 , 20] ) generalizes to all areas of functioning, including social, work, family and marital adjustment domains. The present study’s finding that a reduction in substance-related symptoms was accompanied by improved levels of functioning, social adjustment and enhanced quality of life, provides further support for this point.

In conclusion, there is some preliminary evidence that A-CRA is a promising treatment in the rehabilitation of adolescent substance users in Ireland and culturally similar societies. Clearly, results from a case study have limited generalisability and there is need for larger controlled studies providing robust outcomes to confirm the efficacy of A-CRA in an Irish context. A more systematic study of this issue is in the interest of adolescent substance users and the health services providers faced with the challenge of providing affordable, evidencebased mental health and addiction care to young people.

13. Recommendations to Clinicians and Students

The ACRA model is a structured assemblage of a range of cognitive and behavioural activities (e.g. a rationale and overview of the paradigm, sobriety sampling, functional analyses, communication skills, problem solving skills, refusal skills, jobs counselling, anger management and relapse prevention) which are shared in varying degrees with other CBT approaches. The ACRA model has the advantage of established effectiveness. A foundation in empirical research together with its manual- supported approach results in it being an appropriate “off the shelf ” intervention, highly applicable to many adolescent substance misusers. Such a focussed approach also has the advantage of limiting therapist “drift”. Notwithstanding the accessible manual and other resources available on- line, clinicians and students are strongly encouraged to undergo accredited ACRA training and supervision.

Unfortunately such a structured model, despite its many advantages, does have limitations. This model may not meet the sum of all drug misusing adolescent service user treatment needs, nor is it applicable to all adolescent drug users, particularly highly chaotic individuals with high levels of co- morbidities or multi-morbidities as often found in this population [29 , 30] . Whilst focussing on specifically on drug use, ACRA does not directly address co-existing problem behaviours or challenges such as depression, anxiety, personality disorder, or post traumatic stress disorder (PTSD) synergistically linked to drug use. It is possible that given the high levels of dual diagnoses encountered in this population as well as the compounding effect that drug use exerts on multiple systems, clinicians and practitioners may find a strict application of the ACRA model limiting, necessitating the application of an additional range or layer of psychotherapeutic competencies? Additionally the ACRA model does not focus explicitly on other psychological activities useful in the treatment of drug misuse such as the control and management of unhelpful cognitive styles or habits; breathing or progressive relaxation skills; anger management; imagery, visualisation and mindfulness. That is, as a manual based approach comprising a number of fixed components, a major potential challenge facing clinicians and students is the tension they may experience between maintaining strict fidelity to a pure ACRA approach, versus the flexibility l approved by more formulation driven CBT approaches?

The advantages of a skilled application of a formulation driven approach which are cited and summarised in are multiple and include the collaborative nature of goal setting, the facilitation of problem prioritisation in a meaningful and useful manner; a more immediate direction and structuring of the course of treatment; the provision of a rationale for the most fitting intervention point or spotlight for the treatment; an integration of seemingly unrelated or dissimilar difficulties in a meaningful yet parsimonious fashion; an influence on the choice of procedures and “homework” exercises; theory based mechanisms to understand the dynamics of the therapeutic relationship and a sense of targeted and ‘extra-therapeutic’ issues and how they could be best explained and managed, especially in terms of precipitators or triggers, core beliefs, assumptions and automatic thoughts.

Thus given the above observations and together with the importance placed on engagement and retention, the high variability in the cognitive, emotional, social and developmental domains [4] differences in roles (e.g. teenagers who are also parents) and levels of autonomy as well as high degrees of dual diagnosis or co- morbidities found in this group [29 , 30] practitioners are encouraged to also develop competencies in allied psychological treatment models such as Motivational Interviewing [31] ; familiarity with the core principles of CBT, disorder specific and problem-specific CBT competences, the generic and meta- competences of CBT as well as an advanced knowledge and understanding of mental health problems that will provide practitioners with the confidence and capacity to implement treatment models in a more flexible yet coherent manner,. In addition to seeking supervision and mentorship students and practitioners are directed, as a starting point, to University College London’s excellent resources outlining the competencies required to provide a more comprehensive interventions [11] .

Both authors reported no conflict of interest in the content of this paper.

Author Contributions

Conceived and designed the experiments: JI. Recruitment & assessment and on going treatment t of patient JI. On going supervision of case KD. Contributed reagents/materials/analysis tools: JI, & KD. Wrote the paper: JI. Contributed to final draft paper KD.

Acknowledgments

We thank Adolescent Addiction Services, Health Service Executive.

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Alcohol Withdrawal Case Study (45 min)

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The patient is a 45-year-old male who is a “frequent flyer” in the emergency room for abdominal pain. The patient always has a high ETOH level and demands to be given 3 macaroni and cheese dishes, 2 chicken sandwiches and 2 whole milk cartons. Vital signs are as follows:

Temp 98.6°F orally

Given that he will be admitted to the hospital for a few days without access to alcohol, what protocol medication needs to be ordered for this patient?

• Benzodiazepine (Librium, Ativan)

What question needs to be asked in regard to the patient’s alcohol intake?

• When the last drink was.

The patient reports he drank 2 pints of liquor and a 6-pack of beer tonight.  The patient is telling the nurse that he is serious this time and is going to quit drinking for the holidays so that his family will let him come over for Christmas. The patient is slurring his speech and has a history of trying to elope from the hospital.

What precautions does the nurse need to set up for this patient?

• Seizure precautions, fall precautions and elopement precautions.
• He should also be placed on CIWAA protocol

The patient has an IV line, labs are drawn and the patient has their meal. The blood alcohol level comes back 395 mg/dL. The nurse knows that the patient will metabolize 100 mg/dL every four hours and that the patient is no longer legally intoxicated once it falls to less than 80 mg/dL.

When will this patient likely be no longer legally intoxicated? What is the implication of this time period?

• In 12.6 hours.
• After this point, the patient is at risk for alcohol withdrawal symptoms

What medications will the doctor likely order for this patient to replace vitamins?

• IV fluids with folic acid, thiamine and magnesium sulfate added.
• This is also called a banana bag or rally pack.

The patient has been in the hospital for 14 hours now and is no longer legally intoxicated. The vital signs have stabilized and the patient is alert and oriented x4. The patient remains hopeful to stop drinking and is asking for additional help to stay sober.

What medication could be ordered for this patient to help keep him sober?

What education does this patient need in order to be successful on this medication.

• Avoiding mouthwash, cold medications, aftershaves or anything else that has alcohol in it to avoid having a reaction.
• As well as the reaction (they become immediately ill N/V/D) if they consume alcohol while on Antabuse.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
• 7 Questions
• 5 Questions
• 4 Questions

GI/GU Nursing Case Studies

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Obstetrics Nursing Case Studies

Respiratory nursing case studies.

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Pediatrics Nursing Case Studies

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Neuro Nursing Case Studies

Mental health nursing case studies.

• 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

Substance Use Disorder Case Study

This is a hypothetical example based on our experiences. Our clients’ information is held in strict confidence as a condition of our agreements in every case.

Thomas is a 41-year-old partner at a leading financial firm who is struggling with his  alcohol use . Thomas has tried multiple times to reduce or stop drinking but has yet to succeed. His alcohol use has started to affect his work performance and is straining his relationship with his wife and children. Thomas’ wife contacted OPG for support around creating a treatment plan and helping to find Thomas appropriate and high-quality care that would give him the best chance for success. OPG conducted a consultation with Thomas and his wife, assessing the history of Thomas problems as well as an understanding of his current struggles. With input from the family, OPG staff constructed a consultation report containing a multi-phase treatment plan to put Thomas on the road to recovery. This plan included:

• Recommendations and detailed descriptions for three vetted residential programs that OPG determined are the best fit Thomas’ needs and diagnoses.
• Recommendations for aftercare services upon completion of a residential program.  These Included:   OPG Case Management services ,  Substance Use Monitoring ,  Family Coaching Services , and recommendations for a for a local psychiatrist and therapist.
• OPG care coordination services to ensure continuity and communication amongst providers.

Thomas attended one of the recommended residential faculties for thirty days. Upon completing this program, Thomas worked with an OPG Case Manager while his wife consulted with an OPG Family Coach. Each learned how to best support Thomas in his recovery, with Thomas learning the steps he needed to take to continue his care while his wife learned how best to help him (without enabling and while taking care of herself). Thomas began to see a therapist who specialized in substance use disorders. He also met regularly with an addiction psychiatrist. Thomas’ case manager met with him several times each week in the community, helping him work through the struggles of early recovery.

Thomas was able to achieve sobriety for several months, but, did have one instance where he relapsed while in a high-stress environment (several difficult assignments piled up at work and Thomas struggled, out of pride, to reach out for help). During this time, Thomas’ OPG case manager coordinated with his treatment team and implemented a swift response, increasing the frequency of meetings with Thomas’ case manager as well as with his therapist. Thomas was able to re-engage and was soon back on the path to recovery. Thomas continued to work with his case manager as he became more confident in his sobriety and overtime services were reduced to promote Thomas’ independence.

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Fetal Alcohol Spectrum Disorders: A Case Study

This grand rounds manuscript reviews important considerations in developing case conceptualizations for individuals with a history of prenatal alcohol exposure. This case study provides an introduction to fetal alcohol spectrum disorders, diagnostic issues, a detailed description of the individual's history, presenting symptoms, neuropsychological test results, and an integrated summary. We describe a 9-year old girl diagnosed with a fetal alcohol spectrum disorder (FASD): Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE). This patient is a composite of a prototypical child who participated as part of a research project at the Center for Behavioral Teratology who was subsequently seen at an outpatient child psychiatry facility.

Review of Fetal Alcohol Spectrum Disorders

The estimated prevalence of fetal alcohol spectrum disorders (FASD) is conservatively around 1%; however, a recent study in North America found rates as high as 4.8% of the school-age population is affected by prenatal alcohol exposure, indicating a significant public health concern ( May et al., 2014 ; May et al., 2015 ). While there have been considerable efforts in the public health sector to reduce drinking during pregnancy ( Grant et al., 2004 ), there has not be a meaningful decrease in prenatal alcohol exposure over the past decade ( Thomas, Gonneau, Poole, & Cook, 2014 ). Approximately half of all pregnancies are unplanned and the rates of drinking during childbearing age are substantial; thus, there is ongoing risk of having children born who are affected by prenatal exposure to alcohol ( Finer & Zolna, 2011 ; Green, McKnight-Eily, Tan, Mejia, & Denny, 2016 ).

Prenatal alcohol exposure results in a heterogeneous clinical presentation, which varies greatly in terms of cognitive and behavioral abilities. Prenatal alcohol exposure remains the leading preventable cause of birth defects, developmental disorders, and intellectual disability ( American Academy of Pediatrics, 2000 ). While fetal alcohol syndrome (FAS) has been recognized since the early 1970s ( Jones & Smith, 1973 ), there continues to be difficulty in identifying children affected by prenatal alcohol exposure who do not meet full criteria for FAS. An accepted diagnostic schema to identify children affected by prenatal alcohol exposure has yet to be fully codified in the Diagnostic and Statistical Manual of Mental Disorders - 5 th edition ( DSM-5 ; American Psychiatric Association, 2013 ) or other medical diagnostic system, although positive steps have been made. Unfortunately, a majority of children with FASD are undiagnosed or misdiagnosed due to a lack of characteristic physical features and overlapping symptomology with other disorders ( Chasnoff, Wells, & King, 2015 ).

Overview of Clinical Presentation

Prenatal alcohol exposure results in a wide range of central nervous system dysfunction that is apparent neurologically, structurally, and functionally ( Bertrand et al., 2005 ). Underlying changes in the brain have been shown to relate to increased neurological issues including increased rates of seizures, sleep abnormalities, and sensory processing impairments ( Bell et al., 2010 ; Church & Kaltenbach, 1997 ; Coffman et al., 2012 ; Jan et al., 2010 ; Simmons, Madra, Levy, Riley, & Mattson, 2011 ; Simmons, Thomas, Levy, & Riley, 2010 ; Steinhausen & Spohr, 1998 ; Wengel, Hanlon-Dearman, & Fjeldsted, 2011 ). In addition to neurological signs and symptoms, central nervous system dysfunction can also be evident through the presence of structural brain differences (e.g., microcephaly, structural abnormalities) or functional impairment (e.g., intellectual disability, cognitive deficits).

In some cases, children will meet criteria for a diagnosis of fetal alcohol syndrome (FAS). An FAS diagnosis is characterized by the presence of two or more key facial features (short palpebral fissures, smooth philtrum, thin vermillion border), growth deficits, and evidence of central nervous system abnormalities (e.g., microcephaly, abnormal morphogensis) ( Hoyme et al., 2005 ). For additional detail, please see Figure 1 . It is important to note that the majority of children who are affected by prenatal alcohol exposure do not meet full criteria for an FAS diagnosis and partial phenotypes are important to recognize.

Facial characteristics associated with fetal alcohol exposure. Figure from Warren KR, Hewitt BG, Thomas JD (2011) Fetal alcohol spectrum disorders: Research challenges and opportunities. Alcohol Research and Health 34: 4-14. Figure in the public domain. See Table 1 for more information.

Alcohol is one of the most investigated behavioral teratogens, with decades of research demonstrating the broad behavioral and cognitive effects of prenatal exposure ( Glass, Ware, & Mattson, 2014 ; Mattson, Crocker, & Nguyen, 2011 ). There are a variety of factors that may affect the neurobehavioral consequences of prenatal exposure including genetics, environment, rate and volume of exposure, and other variables related to the pregnancy and development. The timing and dosage of teratogenic exposure to alcohol to the fetus in utero may directly correlate with impairment in specific areas. For example, exposure to alcohol during the first trimester may lead to cerebellar damage related to movement or habit learning whereas second trimester exposure may relate to behavioral or emotional dysregulation as the amygdala development may be atypical. As of now, there is no safe dosage or timing in which to drink and pregnant women are recommended by the Surgeon General to not drink throughout pregnancy. Further, the exact relations between dosage and timing of exposure and behavioral effects is still largely unknown and likely varies dramatically based on other characteristics such as speed of metabolism of alcohol, other genetic factors, other potential comorbidities, and environmental effects. Often alcohol is not the only teratogen and there may be concerns related to nutritional status and other factors that affect both the pregnancy and long term behavioral outcomes of the child. Understanding the relation between neurological insult and behavioral presentation can help inform intervention. However, there have been consistent findings across studies that point to an emerging neurobehavioral profile associated with prenatal alcohol exposure ( Mattson & Riley, 2011 ; Mattson et al., 2013 ).

Behavioral Deficits/Self-Regulation

Behavioral deficits are often the impetus to seek clinical care for individuals affected by prenatal alcohol exposure. Across studies, there has been repeated confirmation of behavioral concerns related to self-regulation and externalizing problems such as impulsivity and rule-breaking, in addition to inattention, anxiety, depression, and poor social functioning ( Glass et al., 2014 ; Mattson et al., 2011 ; Streissguth et al., 2004 ). Children with prenatal alcohol exposure have higher rates of concomitant psychopathology, including increased rates of psychopathology, negative affect, and overall mood lability ( Burd, Klug, Martsolf, & Kerbeshian, 2003 ; Sood et al., 2001 ; Streissguth et al., 2004 ). Further, studies consistently support the presence of attention deficits in children who have histories of prenatal exposure to alcohol, with rates of attention-deficit/hyperactivity disorder (ADHD) diagnoses estimated between 40-90% ( Bhatara, Loudenberg, & Ellis, 2006 ; Burd et al., 2003 ; Fryer, McGee, Matt, Riley & Mattson, 2007 ).

Adaptive Functioning

Another core feature of the clinical presentation associated with prenatal alcohol exposure is the presence of impaired adaptive behavior. Adaptive behavior deficits have been noted across all domains of adaptive function (i.e., communication, socialization, motor skills, and daily living skills) and appear to worsen with age ( Carr, Agnihotri, & Keightley, 2010 ; Crocker, Vaurio, Riley, & Mattson, 2009 ; Jirikowic, Carmichael Olson, & Kartin, 2008 ). In terms of communication, many children with prenatal alcohol exposure demonstrate deficits in aspects of language including phonological processing, speech production, and social communication ( Doyle & Mattson, 2015 ). Social skills are complex and often considered the most severely affected domain of adaptive functioning in children with prenatal alcohol exposure. Alcohol-exposed children have routinely been found to demonstrate poor social interactions and struggle with socially inappropriate behavior ( Greenbaum, Stevens, Nash, Koren, & Rovet, 2009 ; McGee, Fryer, Bjorkquist, Mattson, & Riley, 2008 ). Children with prenatal alcohol exposure also have difficulty with motor control ( Kalberg et al., 2006 ; Simmons, Thomas, Levy, & Riley, 2006 ). Daily living skills are often impaired or delayed in children with prenatal alcohol exposure and are apparent both in delayed reaching of developmental milestones (e.g., toileting, following rules, bathing, feeding) and overall difficulty with living independently, although there is minimal research conducted within adult samples ( Moore & Riley, 2015 ). Difficulties in adaptive function often appear to persist into adulthood, although there are anecdotal reports of both improved and worsening behavioral concerns. As prenatal alcohol exposure results in damage to the brain, it is likely that deficits in this area are related to the prenatal neurological striatal insult that can result in poor habit learning requiring instructions to be repeated more often and not learning effective strategies for functioning in social and practical situations as quickly as typically developing youth. These issues seen in childhood may be exacerbated in adulthood as the gap between what is expected of the individual and what the individual is able to do may grow. Further, as adults individuals often have more freedom and access to situations that may lead to more high risk behavior and negative outcomes. These adaptive behavior problems often lead to secondary disabilities, including high rates of interaction with the justice system, lower rates of independent living, and high rates of substance abuse ( Streissguth, Barr, Kogan, & Bookstein, 1996 ).

Neurocognitive Functioning

In addition to behavioral deficits, cognitive effects of prenatal alcohol exposure are well documented and have been reviewed in depth (see Glass et al., 2014 ; Mattson et al., 2011 for review). Overall, prenatal alcohol exposure results in cognitive deficits across various domains, including general intellectual function, executive function, learning, memory, and visual spatial reasoning. The literature on impairments in these domains is the basis for the proposed criteria of Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE), which is in the appendix of the DSM-5 as a condition for further review ( Doyle & Mattson, 2015 ; Kable et al., 2016 ).

One of the most robust findings in children with prenatal exposure to alcohol is overall diminished general cognitive function. Average intelligence estimate scores among children exposed to alcohol prenatally fall approximately 1 standard deviation lower than the average non-exposed individual ( Glass et al., 2013 ; Streissguth et al., 2004 ), although individuals can range from severe impairment to unimpaired (e.g., full scale IQ scores of 40-112; Mattson et al., 2011 ). Executive dysfunction is often considered a core feature of prenatal alcohol exposure and poor performance on these higher-order domains is seen across parent report and objective standardized assessments ( Glass et al., 2014 ; Mattson et al., 2011 ; Nguyen et al., 2014 ). Deficits exist across aspects of executive function including planning, set-shifting, cognitive flexibility, response inhibition, and working memory.

Alcohol-exposed children also struggle with poor performance in learning new material, both in visual and verbal domains, with stronger support for the latter ( Mattson et al., 2011 ; Pei, Rinaldi, Rasmussen, Massey, & Massey, 2008 ; Willford, Richardson, Leech, & Day, 2004 ; Willoughby, Sheard, Nash, & Rovet, 2008 ). Learning deficits are also apparent in the presence of decreased academic performance across domains, with particular weaknesses seen in areas of mathematical functioning ( Glass, Graham, Akshoomoff, & Mattson, 2015 ; Goldschmidt, Richardson, Stoffer, Geva, & Day, 1996 ; Howell et al., 2006 ). Memory deficits are also seen across domains (verbal, visual, auditory), and often appear to be associated with initial encoding difficulties with relatively spared retention ( Kaemingk, Mulvaney, & Halverson, 2003 ; Willoughby et al., 2008 ). Children with prenatal alcohol exposure also have difficulties processing visual information ( Mattson et al., 2011 ; Mattson, Gramling, Delis, Jones, & Riley, 1996 ; Paolozza et al., 2014 ), which can relate to poor performance in several areas of functioning ( Crocker, Riley, & Mattson, 2015 ).

Diagnostic Issues

While it appears that training pediatricians on recognizing dysmorphology is effective in increasing awareness and identification of children with FAS ( Jones et al., 2006 ), the vast majority of children affected by prenatal alcohol exposure do not meet criteria for the diagnosis and are at high risk of not receiving necessary services in spite of significant cognitive and behavioral challenges. There are various factors that hinder clinical identification of alcohol-exposed children including high rates of symptoms that overlap with other clinical disorders (e.g., ADHD), no biomarker to date, lack of prenatal exposure information, and often no obvious facial dysmorphology. Objective screening tools, including neonatal testing and the development of potential biomarkers, can assist in the identification of alcohol-exposed children at birth ( Koren et al., 2014 ; Zelner et al., 2010 ; Zelner et al., 2012 ); however, these tools have not been introduced as best practice guidelines at this point and remain in a research phase. Ongoing study is needed to determine the accuracy and reduce the risk of disproportionately targeting specific groups, inaccurate screening, and address the concern of stigma and judgment associated with maternal drinking during pregnancy ( Drabble, Thomas, O'Connor, & Roberts, 2014 ; Yan, Bell, & Racine, 2014 ). A common concern in development of identification tools for alcohol exposure at birth is that even if it is possible to accurately determine prenatal alcohol exposure with adequate sensitivity and specificity, it is not certain that an individual will be negatively affected later in life. As such, tools targeted at identifying affected individuals (vs. exposed individuals) may be most beneficial in assuring proper allocation of interventions and resources.

Further complicating access to services, many children with histories of prenatal alcohol exposure are placed in foster or adoptive care and, unfortunately, documentation of concerns or discussion of the potential effects of prenatal alcohol exposure are often unavailable or unclear. Many reasons exist for the lack of accurate or comprehensive prenatal exposure information such as biological mothers not disclosing for any reason, including stigma related to drinking during pregnancy, and medical professionals not routinely asking about substance use during pregnancy. It is important for clinicians to ask about alcohol exposure (and other teratogenic exposures) both in the preventative context for all women of childbearing age, during pregnancy specifically inquiring about drinking habits pre- and post-pregnancy recognition, as well as in child-visits to ask the parent about prenatal exposure during pregnancy. Conducting a comprehensive interview to understand a woman's baseline alcohol-use pattern can be pertinent in determining rates or risk of alcohol-exposure. Parents may not wish to disclose drinking during pregnancy (affecting both biological and foster care placements) and often it is not until a child develops a significant issue in school that this issue comes to light, at which time records may or may not be reviewed and followed up. Therefore, many affected children may have no information regarding prenatal exposure causing the etiology of behavioral or cognitive dysfunction to never be fully elucidated. Lastly, as there has not been a unanimous agreement for a codified system of diagnostic criteria for alcohol-related diagnoses beyond fetal alcohol syndrome, there is a history of various criteria being used to define or categorize effects of prenatal alcohol exposure. Most recently, the DSM-5 has proposed the following criteria after consulting with experts in the field. As the DSM-5 is the most utilized diagnostic manual for mental health disorders in the U.S., is commonly used in access to services at schools, and informs insurance reimbursement, we have focused on these criteria for the current manuscript. Further, the criteria generally map on to the most recently released updated clinical guidelines related to prenatal alcohol exposure ( Hoyme, et al., 2016 ).

Proposed Diagnostic Scheme

A proposed diagnostic system to identify the effects of prenatal alcohol exposure has been incorporated into the DSM-5 as a condition requiring further study, referred to as ND-PAE ( American Psychiatric Association, 2013 ). A similar term, Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure, is listed as a prototypical example under Other Specified Neurodevelopmental Disorder (315.8, F88). The criteria for ND-PAE require indication that the individual was exposed to alcohol at some point during gestation (including prior to pregnancy recognition) and that the exposure was more than “minimal.” The precise dosage is not specific and relies on clinical judgment, although a suggested estimate for minimal exposure is defined as 1–13 drinks per month during pregnancy (and never more than 2 drinks on any one drinking occasion ( American Psychiatric Association, 2013 ). In addition to exceeding a minimal level of prenatal alcohol exposure, the individual must also display impaired neurocognition, self-regulation, and adaptive functioning. As the location of the disorder in the appendix of DSM-5 (“conditions for further study”) suggests ongoing research is required to determine the feasibility, sensitivity, and specificity of the proposed criteria to accurately identify those affected by prenatal alcohol exposure ( Kable et al., 2016 ).

A common clinical situation occurs when a child presents to an outpatient clinic with myriad other diagnoses – ADHD, adjustment disorder, reactive attachment disorder, mood disorder not otherwise specified, post-traumatic stress disorder (PTSD), and a learning disability – for which a diagnosis of ND-PAE may more parsimoniously encapsulate and holistically conceptualize the case. Pediatricians or mental health professionals may not be adequately trained on how to integrate information regarding prenatal alcohol exposure into their practice or the information regarding prenatal exposure may not readily available ( Gahagan et al., 2006 ; Rojmahamongkol, Cheema-Hasan, & Weitzman, 2015 ). Further, the diagnosis may be stigmatizing and thus providers may be hesitant to discuss it with the family ( Zizzo et al., 2013 ).

Support for Assessment

Given the heterogeneous neurobehavioral profile associated with prenatal alcohol exposure, a comprehensive neuropsychological examination is recommended. The assessment ideally covers the criteria associated with a diagnosis of ND-PAE (see Figure 2 ; American Psychiatric Association, 2013 ). Doyle and Mattson (2015) have reviewed variety of valid, reliable neuropsychological and parent-report measures that assess neurocognitive functioning, behavioral self-regulation, and adaptive functioning. Once a full assessment is conducted, a comprehensive case conceptualization requires a significant records review. Often the diagnosis, as discussed, is difficult as there may be a variety of distinct diagnostic categories that are met for each child. There is a strong emphasis on clinical judgment to determine the most parsimonious and accurate diagnoses, while also considering access to needed services.

Core symptoms for Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE). For complete criteria see American Psychiatric Association, 2013 , Diagnostic and statistical manual of mental disorders, DSM-5 (5th ed.), pp. 798-799.

Once a diagnosis is given, advocacy for the child becomes a priority both at school and at home ( Boys et al., 2016 ), ideally with collaboration across various settings and providers. A behavioral analysis to understand what factors are contributing to poor performance is beneficial in order to develop effective treatment recommendations. Clinicians and researchers have advocated for the importance of specific modifications in teaching strategies and classroom environments to aid children with histories of prenatal alcohol exposure ( Green, 2007 ; Kalberg & Buckley, 2006 ; Kodituwakku & Kodituwakku, 2011 ; Premji, Benzies, Serrett, & Hayden, 2007 ). Despite advances in understanding the precise neuropsychological deficits associated with FASD, very few empirically supported interventions are available ( Burd et al., 2003 ; Kodituwakku & Kodituwakku, 2011 ). Targeted interventions ( Adnams et al., 2007 ; Kable, Taddeo, Strickland, & Coles, 2015 ; Kable, Coles, & Taddeo, 2007 ; Peadon, Rhys-Jones, Bower, & Elliott, 2009 ) and patient advocacy ( Boys et al., 2016 ; Duquette, Stodel, Fullarton, & Hagglund, 2006 ) can facilitate outcomes, although this is a significant area of need both in terms of development and dissemination. Early identification and effective treatments for alcohol-exposed children could result in better outcomes; however, both are currently limited in terms of access to services and the generation of effective interventions ( Bertrand et al., 2005 ; Kodituwakku & Kodituwakku, 2011 ; Premji et al., 2007 ).

School systems and other providers may or may not be familiar with the effects of prenatal alcohol exposure and may benefit from additional psychoeducation. Support for the child in the development of an individualized education plan or special services, as indicated by the effect of prenatal alcohol exposure on learning, may be necessary. Additional considerations could include repurposing interventions targeted within other populations for children with alcohol-exposure, although they may need to substantially modified to be successful in this population.. Often, alcohol-exposed individuals are complex and require evaluating the situation from a holistic, multifaceted bio-psychosocial perspective, including collaboration between various settings and providers and implementing interventions in a number of systems and environments (e.g., school, home, parent-training, outside support, physical therapy, occupational therapy, speech and language pathology, vocational training). Additional information regarding interventions and treatment recommendations will be discussed at the end of the case study.

REASON FOR REFERRAL AND BACKGROUND HISTORY

The case presented here, referred to as Jane, is a composite of cases seen in a research project at the Center for Behavioral Teratology who were then subsequently seen at an outpatient child psychiatry facility. Thus, the data represents a prototypical child seen at the facility. Jane is a 9-year-old, right-handed, monolingual English speaking girl in the 3 rd grade. She was referred by her primary care physician for a neuropsychological evaluation to assess her current level of neurocognitive functioning due to parent reported behavioral problems, emotional concerns, and poor school performance. The following background history was obtained from an interview with Jane and her adoptive mother, Mrs. Smith. Mrs. Smith expressed significant concerns regarding fears of Jane being held back at school and inability to “control Jane” at home and around other children.

Per clinical interview with Mrs. Smith and review of records, Jane has had significant behavioral concerns since she was a toddler. These include explosive tantrums, aggressive behavior, and difficulty with emotional regulation and self-soothing. Jane had been in three different residential/foster care placements and was most recently transitioned to a foster-to-adopt placement in first grade with Mr. and Mrs. Smith. She has adapted well to this placement and was officially adopted by Mr. and Mrs. Smith in the beginning of this year, prior to starting 3 rd grade. Jane has been engaged in family therapy, which has focused on attachment issues and evidence based treatment and parent-training for behavioral concerns; however, she still shows significant deficits that require “round the clock care” according to Mrs. Smith. While social skills training has been recommended, they have not been able to fit it into their schedules at this time.

Mrs. Smith noted that Jane has had significant tantrums and difficulties with self-control. She often provokes fights with other children and can have significant tantrums that last for over an hour, which include crying, screaming, destroying property, and hurting others. This in part led to the frequent changes in placement early in her life as other foster parents “could not handle her behavior.” Behavioral concerns also included impulsivity, difficulties with maintaining attention on specific tasks, difficulty following directions, and some aggressive behaviors including hitting and kicking her peers and parents. As she grew older, her behaviors continued and became more sophisticated: she began lying (for example, she broke several toys and then blamed it on another foster child in the home), and stealing items from others in the household. The new placement, engagement in therapy, and utilization of parent-training has successfully reduced the frequency of tantrums to approximately once a week, although they maintain similar severity, which is not developmentally appropriate. These behaviors most often occur at home, although she repeatedly needs to be redirected to on-task behavior at school as well. Her teachers express concern regarding her ability to stay on task and complete work, though have not witnesses the same frequency or severity of behavioral outbursts that are reported at home.

Jane has been seen by several different mental health professionals and continues to be engaged in both behavioral therapy and psychopharmacological intervention. She has a current clinical diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), combined presentation, that was originally diagnosed at age 6. Due to difficulties in social interactions, she was assessed for an autism spectrum disorder at the age of 3, which was ruled out at that time. Jane was able to perform adequately in elementary school through second grade, with some difficulties surrounding the transition to a new school in first grade. However, since beginning third grade, she has had difficulty with increasing cognitive, behavioral, and social demands and is currently at risk of not transitioning to fourth grade with her peers. She has been suspended twice from this elementary school due to inappropriate behavior (i.e., inappropriately touching another peer, throwing her chair, not following directions, and breaking a computer).

The potential for Jane to be assessed for and potentially qualify for an individual education plan (IEP) had been brought up by her parents and teachers in 2 nd grade, though the school district decided that at that time she has yet to meet criteria for significant services as she was not significantly behind in her academic achievement. She currently has a 504 plan that provides minimal behavioral accommodations. Her parents are currently in process of requesting another IEP evaluation at the school. Jane was assessed by a school psychologist at the age of 7 upon entering first grade and was not found to meet criteria for intellectual disability (IQ = 78, no evidence of specific learning disability), though had significant difficulty with aspects of adaptive functioning. In that evaluation she also received a diagnosis of ADHD and a prescription of a non-stimulant medication (Straterra). Her mother reports that this medication has been minimally effective though expressed concern regarding additional medications or stimulant medication due to potential side effects. For example, there has been concern regarding maintaining weight gain, given that she has a relatively low body mass index. She was assessed for services by the school under the other health impairment (OHI) criterion and a 504 plan was initiated at that time in which she received several accommodations including preferential seating at the front of the task and extra time on assignments.

In many cases regarding prenatal exposure, a comprehensive review of records is imperative as there are often complex biopsychosocial risk factors that may impact functioning. Many children with histories of prenatal alcohol exposure have backgrounds remarkable for social service involvement and potential foster/adoption care. In this case, Jane was born after 32 weeks gestation. Per the hospital records and adoption telling, her biological mother reported drinking before and during pregnancy (several drinks during the day and generally in a binge drinking pattern, 4-5 drinks a day on weekends, “sometimes that much on a weekday”). Per these records, the biological mother and father also reported occasionally using methamphetamine and marijuana. The biological mother reported pregnancy recognition at 5.5 months, at which time she attempted to cut down on her alcohol and substance use. She reported only binge drinking “occasionally” since knowing she was pregnant, though continued to drink greater than four drinks per occasion on several weekends during her third trimester. This pattern of reducing drinking later during pregnancy appears to be common based on our clinical and research interviews, therefore detailed maternal screening for alcohol exposure to the fetus both pre and post pregnancy recognition is imperative. Conducting a detailed interview of baseline substance use and lifestyle factors prior to the pregnancy can also provide important information on drinking patterns that may be underreported during pregnancy. Further, patterns of drinking may change during a pregnancy, as in this case, which is be important to note and investigate. In this case, Jane's biological mother reported minimal prenatal care and her nutritional status was unclear throughout the pregnancy.

Child protective services removed Jane from her biological mother's care at the hospital when she had a positive toxicology screen at birth for methamphetamine and Jane's biological mother relinquished her rights at that time. Jane was placed in a foster care home after discharge. At the one year well-child pediatric appointment Jane was referred to a dysmorphologist after the foster parent disclosed Jane's prenatal history based on her records. Jane was evaluated by a dysmorphologist with expertise in FAS (See Table 1 , Figure 1 ). Jane was in the 7 th percentile for height and 4 th percentile for weight, consistent with FAS criteria for growth deficiency, though she did not meet full facial dysmorphology criteria for FAS. She met all developmental milestones, generally on the later end. Per the foster care records, she did not crawl until she was 17 months and had received “on and off” occupational and physical therapy between the ages of 1 and 4. Her adoptive mother noted that when Jane was placed with them, there were no developmental delays for speech or language, though noted she is still quite “clumsy”.

Summary and Comparison of the Various Diagnostic Schemas for Prenatal Alcohol Related Disorders. Table adapted and updated from Warren KR, Hewitt BG, Thomas JD (2011) Fetal alcohol spectrum disorders: Research challenges and opportunities. Alcohol Research and Health 34: 4-14. In the public domain.

Psychosocial History

Jane currently lives with her adoptive mother and father along with two other children, who are also adopted. Of note, Jane frequently steals her sibling's toys and will hide broken toys and lie about how they were broken. When confronted, Jane often has tantrums resulting in tears and acting aggressively towards her mother (e.g., kicking, hitting). In these situations, her mother views her as “acting much younger age than she really is.” Jane reported to the examiner that she has many friends; however, her mother reports that she does not get invited to friend's houses and her teachers report repeated difficulty with peer interactions. Generally, Jane gets along better with peers and neighbors who are two to three years younger than she is. As a younger child, Jane's mother reported that Jane had difficulty interacting in peer situations, often talking over others in conversations or invading other's personal space.

Academic History

Jane's educational history is complicated by her frequent placement changes and she switched schools several times before her current stable placement. She attended preschool between the ages of 3-5 and had a series of behavioral concerns including reports of hiding under her desk, attachment difficulties with foster parents, not following directions, not completing assignments, yelling during class, often getting up from her seat, interrupting peers and the teacher, and not responding or listening to consequences. She has previously been assessed for additional services and has an active 504 plan (she sits near the front of the class, gets extra time on assignments, written reminders and a calendar to help with homework). Jane is currently performing poorly in third grade. She often fails to complete assignments (often crumpled at the bottom of her backpack). Further, she almost two grades behind in math, and one grade behind in reading and spelling. Per her teachers she has particular difficulty with complex math word problems and reading comprehension. She is not pulled out of class for any additional help and receives no tutoring.

Psychiatric History

Currently, Jane is being treated for irritability, mood symptoms and diagnosis of ADHD with a combination of outpatient therapy and medications. Despite the earlier concern regarding weight gain and side effects of medications, since the original evaluation at the age of 7 she has moved to a new psychiatrist and currently takes Prozac (10 mg daily), Clonidine (0.1 mg in the morning and 0.2 mg in the evening), Adderall XR (20 mg daily), and Risperdal (0.25 mg), as prescribed. Of note, there is very little research on medication dosage or efficacy in this population. Further, similar to the various diagnoses that a child with this profile may receive, medications prescribed may also be compounded. Jane's prescribed medications are not uncommon for this population as many children with fetal alcohol spectrum disorders are treated psychopharmacologically using multiple medications. There is preliminary evidence that alcohol-exposed children may respond differently to medication ( Doig et al., 2008 ). Currently psychiatrists familiar with prenatal alcohol exposure may tend to start at lower doses and increase at a slower rate to help effectively treat behavioral symptoms. To date, there has not been case-control studies to inform published guidelines on psychiatric medication for alcohol-exposed children.

Medical History

As previously discussed, Jane's biological parents have a history of substance abuse problems. Per review of records, Jane's birth was unremarkable with the exception of prenatal exposure to alcohol and drugs and lack of prenatal care. Within her first year, records indicate that she exhibited “failure to thrive.” Growth failure has continued and Jane will occasionally refuse to eat or, at other times, not monitor her eating and overeat to the point of vomiting. Other information regarding her biological parents or family history is unknown. She has no history of seizures or traumatic brain injury, and has never been in any serious accidents. Jane, fortunately, does not have a significant medical history or neurological concerns that would further complicate her cognitive profile. If there were cause for concern regarding a neurological insult or injury, a consult with a neurologist or other medical professionals may be recommended. At this point, neuroimaging studies have primarily been conducted in research settings rather than as part of a clinical protocol. While there is a substantial literature on brain injury and imaging findings in this population, the field is not yet at the point where imaging would necessarily lead to meaningful clinical implications in most cases. Potential consults with other disciplines (i.e., occupational therapy, speech therapy, physical therapy, educational specialist, feeding specialist, pediatrician, neurologist, and psychiatrist) may be indicated as well. Please see Figure 3 for general referral process.

Framework for FAS Diagnosis and Services. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. National Center on Birth Defects and Developmental Disabilities, Center for Disease Control and Prevention, Department of Health and Human Services in coordination with National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect. 2004. http://www.cdc.gov/ncbddd/fasd/documents/FAS_guidelines_accessible.pdf . In the public domain.

Current Testing

Testing was completed across two days. Jane reportedly took all of her medications as prescribed. Jane had been previously examined by a pediatric dysmorphologist and was recently re-assessed as part of her continuing general care. While Jane's height and weight remained below the 10 th percentile for her age and sex, indicating a growth deficiency, she did not meet criteria for microcephaly or display facial dysmorphology required for a medical ICD code, and thus would not qualify for an alcohol related diagnosis of FAS or partial FAS (see Table 1 , Figure 1 ).

Neuropsychological Assessment Results

The purpose of this evaluation was to identify any learning or cognitive difficulties, determine whether any observed deficits are consistent with a specific etiology, and provide this information to her family, teachers, and physicians to help formulate a possible diagnosis and treatment plan. Of note, as mentioned this case is a composite of a prototypical child who participated as part of a research project at the Center for Behavioral Teratology who was subsequently seen at an outpatient child psychiatry facility. Depending on the assessment setting, there may be a variations in the amount of neuropsychological testing that is feasible, for example in a general outpatient assessment center, a child may be able to receive a comprehensive neuropsychological battery conducted over several days or if a child is seen within a pediatrician's office, they may only receive very brief assessment or screening. This case attempts to balance a more comprehensive assessment with feasibility concerns as this battery could be completed during one day (for example, only giving certain subtests of the WIAT-III, not giving additional parent report measures). For additional information on ND-PAE and appropriate assessment protocols, please refer to Kable et al., 2016 and Doyle and Mattson, 2015 .

Current Functioning Based on Self-Report

Jane reported that her current mood is “okay.” She did not endorse any difficulties with sleep or appetite. She reported no pain (0/10), though showed the examiner a Band-Aid from a fall the previous week. She reported no weakness or numbness and her gait/balance was grossly within normal limits.

Behavioral Observations

Jane arrived on time accompanied by her mother. She was cooperative and felt comfortable with testing, noting once that some measures appeared familiar. She had adequate frustration tolerance, though repeatedly asked for breaks and “when it would be over.” She understood all test questions and had adequate vision and hearing. She did not wear corrective lenses or a hearing aid. Her levels of attention and concentration were adequate to complete the testing. She was able to understand the test instructions and only occasionally required repetitions. She required redirection to task when given individual subtests without direct interaction with the examiner (i.e., WIAT-III numerical operations, CPT-3). Her speech was at a normal volume, with a normal rate and rhythm. She often asked the examiner questions about her background and had to be redirected to the task at hand.

Jane appeared to be alert and oriented throughout the testing process. She appeared well groomed, with generally good hygiene, casual dress, and appeared her stated age. Jane maintained euthymic affect throughout most of the interview and testing and spontaneously participated in conversation with the examiner. During assessment, she exhibited appropriate eye contact, although was consistently hyperactive and fidgety throughout the testing. Her thought process was logical and goal-directed, and her thought content was normal and appropriate to the situation. She consistently demonstrated effort to perform well on the various subtests administered and performed at expectation on objective measures of validity; thus, these results appear to be a valid indication of her cognitive and behavioral abilities at the time. Jane took her medications as prescribed on the days of the assessment; therefore, her cognitive and behavioral abilities reflected in the results of this assessment are not representative of her abilities without these medications.

Results of Testing

The neuropsychological assessment included measures of global intellectual performance, executive functioning, learning, memory, and visual-spatial reasoning to evaluate neurocognitive functioning as defined by ND-PAE (see Figure 2 ). The behavioral questionnaires and parent interviews captured information regarding Jane's self-regulation, behavioral functioning, and adaptive behavior. The table below provides information on the scores and descriptions of performance.

Tests Administered

Child Behavior Checklist (CBCL) ( Achenbach & Rescorla, 2001 )

California Verbal Learning Test, Children's Version (CVLT-C) ( Delis et al., 1994 )

Conners Continuous Performance Test, Third Edition (CPT-3) ( Conners, 2014 )

Delis-Kaplan Executive Function System (D-KEFS) ( Delis, Kaplan & Kramer, 2001 )

Finger Tapping Test, Grooved Pegboard (Norms: Strauss, Sherman & Spreen, 2006 ).

NIMH Diagnostic Interview Schedule for Children Version IV, Computerized Version (C-DISC-4.0) ( Shaffer et al., 2000 )

NEPSY, 2 nd edition ( Korkman, Kirk & Kemp, 2007 )

Wechsler Intelligence Test for Children, Fifth Edition (WISC-V) ( Wechsler, 2015 )

Wechsler Individual Achievement Test, Third Edition (WIAT-III) ( Wechsler, 2009 )

Vineland Adaptive Behavior Scale, Second Edition (VABS-II) ( Sparrow, Cicchetti & Balla, 2005 )

NEUROCOGNITIVE FUNCTIONING

Self-regulation, adaptive behavior, integrated evaluation and diagnostic interpretation.

Jane is a 9-year-old, right-handed girl referred by her primary care physician for a neuropsychological evaluation to assess her current level of neurocognitive functioning due to behavioral concerns and poor school performance. Overall, the current neuropsychological evaluation revealed a variety of weaknesses and several strengths on the domains tested. Jane demonstrated low average cognitive abilities, as her full scale IQ estimate, which is a combination of all index scores, was approximately one and a half deviations below the mean (WISC-V, FSIQ=79, 8 th percentile). This is in line with research on children with heavy prenatal alcohol exposure with IQ estimates generally between one and two standard deviations below the mean. In her case, this global estimate of functioning should be interpreted with caution as there was significant variability between the index scores with relative strengths seen in verbal comprehension (WISC-V VCI, SS=92, 30 th percentile) and relative weaknesses seen on working memory and fluid reasoning (WISC-V WMI, SS= 74, 4 th percentile; FRI SS=74, 4 th percentile) There was also significant spread within domains, for example on processing, She was in the average range for a task requiring her to have rapidly scan and match a target to a sample of items but was in the borderline range when asked to associate symbols and numbers in a rapid fashion.

In terms of academic functioning, Jane performed below her current grade level (3 rd grade) on all achievement measures (reading, writing, math). She demonstrated relative strengths in reading (WIAT-III Basic Reading, SS=90, 25 th percentile) and spelling (WIAT-III Spelling, SS=88, 21 st percentile) and relative weaknesses in math, evident on both a written math worksheet (WIAT-III Numerical Operations, SS=73, 4 th percentile) and math problem solving (WIAT-III Math Problem Solving, SS=69, 2 nd percentile). On spelling measures she made errors that were phonemically consistent. In terms of math, she had difficulty completing even simple problems and she often tried to rush through questions if she did not know how to do them or would become upset. When asked to try, she would make mistakes that demonstrated she had no automaticity in regards to number facts..

Taken together, this pattern is emblematic of a specific learning disability in mathematical functioning. Jane has experienced difficulties learning and using academic skills, in particular within the domain of math, for several years based on her parent reports and standardized assessments. She demonstrated low average to low performance on her ability to master calculation, math word problems and number facts. Her mother and teachers note that Jane gets lost in the middle of math problems, forgets the rule she was supposed to follow, and often becomes upset and does not want to continue further. This was consistent with our assessment and an examination of her homework. Jane also had difficulty with mathematical reasoning and applying mathematical concepts to solve problems. She has been able to compensate to some extent with her other cognitive strengths, though continues to struggle in this domain. Her math skills were substantially and quantifiably below those expected for her age and cause significant interference for her academic performance, especially when considered in the context of standardized testing.

Jane's performance on measures of executive function was also below expectation. She demonstrated impairment on a measure of selective auditory attention and vigilance (NEPSY-II Auditory Attention, SS=3, 1 st percentile), and was borderline range in her ability to cognitive shift and inhibit her responses (NEPSY-II Response Set, 2 nd percentile). She had average verbal fluency, visual scanning, and motor speed, although demonstrated difficulties on tasks involving inhibitory control or cognitive flexibility, such as in switching tasks (D-KEFS Color Word Interference Inhibition, SS=6, 9 th percentile; Color Word Interference Inhibition/Switching, SS=5, 5 th percentile; Trail Making Test Number-Letter Switching, SS=2, <1 st percentile). She also demonstrated an isolated difficulty in number sequencing (D-KEFS Trail Making Test-Number Sequencing, SS=3, <2 nd percentile), which was not seen on letter sequencing. Overall, Jane demonstrates particular difficulty with higher order executive function tasks and selective attention, while basic fluency, color naming, and reading abilities remain intact.

In terms of memory, Jane demonstrated impairment on both verbal and visual memory at immediate and delayed conditions. She had difficulty in learning a list of words, after hearing the list five times she was able to remember only 7 of the 15 words (CVLT-C total list A, T=20, <1 st percentile), however a delay she was able to remember all of the words she learned initially illustrating poor encoding, but intact retention. She demonstrated intact performance on some aspects of memory, including memory for faces and memory for names, though had more difficulty with remembering verbal information even when given context (NEPSY-II Narrative Memory, SS=5, 5 th percentile) and more complex visual information both immediately and after a delay (NEPSY-II Memory for Designs, SS=5, 5 th percentile). Regarding visual-spatial processing, she demonstrated low average ability on the WISC-V visual spatial tasks (Block Design, Matrix Reasoning) and on a measure where she had to copy designs though had intact performance on a separate visual puzzle task and on a measure of visuomotor integration. Jane also completed a computerized measure of attention difficulties and demonstrated elevated omission scores (CPT-3 Omissions, T=67, 97 th percentile) and average commission scores (CPT-3 Commissions, T=57, 75 th percentile), which indicates the presence of inattention though not hyperactivity. It is important to note that she was on medication for ADHD at the time of testing.

Regarding her emotional functioning, Jane's mother reported clinically significant elevations on several scales, including: anxious/depressed, social problems, and attention problems. Withdrawn/depressed, somatic complaints, thought problems, and rule-breaking behavior were within the borderline range. According to the clinician-assisted interview, she met positive criteria for ADHD, oppositional defiant disorder (ODD), conduct disorder (CD), and separation anxiety. In terms of adaptive behavior, Jane's parents indicated that her communication (VABS-II Communication, SS=75, 5 th percentile), socialization (VABS-II Social Skills, SS=78, 7 th percentile), daily living (VABS-II Daily Living Skills, SS=73, 4 th percentile) and overall adaptive function (VABS-II, Total, SS=74, 4 th percentile) were all moderately low for her age. In terms of motor skills, her gross motor abilities were intact bilaterally. She demonstrated a relative weakness on fine motor skills on her dominant hand (R), though her non-dominant fine motor skills were intact.

Taken together, Jane's neuropsychological profile is characterized by weaknesses in executive function (working memory, cognitive flexibility, inhibitory control), learning, memory (visual and verbal), and academic achievement, in particular concerns with math. She has mixed performance on visual-spatial reasoning, and intact performance on language measures, gross motor skills, hyperactivity, aspects of memory (faces, names), fluency, and motor speed. Per parent and collateral reports with her therapist and teacher, significant mood regulation and adaptive behavior concerns are evident, particularly in externalizing behaviors.

While her math difficulties are potentially related to prenatal alcohol exposure, it is impossible to determine that they would be fully due to an alcohol-related condition and therefore Jane meets criteria for a diagnosis of a specific learning disorder with impairment is math. Likely her math performance is related to her lower working memory and perceptual reasoning abilities, which affected her calculation and problem solving abilities.

Her parents were given a standardized, semi-structured clinical interview, the Computerized Diagnostic Interview Schedule for Children Version IV (C-DISC-4.0) ( Shaffer et al., 2000 ). In other clinical contexts, there are various other published structured clinical schedules or other comprhensive clinical interviews can be utilized. For Jane, while the C-DISC-4.0 illustrates several diagnoses in which she meets DSM - IV criteria, her profile of functioning may be most parsimoniously conceptualized as meeting criteria for the Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure diagnosis, which is listed as a condition for further study in DSM-5. Therefore, her symptomology would be best captured by the Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure, under the Other Specified Neurodevelopmental Disorder DSM Code (315.8, ICD F88). She also continues to meet criteria for ADHD, combined presentation, per clinician, teacher, and parent-reports, as well as behavioral performance based on objective testing. Both poor math performance and symptoms of ADHD are also criteria in ND-PAE. These diagnoses are given in addition to ND-PAE as she qualifies for all three independently. A similar pattern is seen with children who meet criteria for ADHD and depressive disorders or ADHD and ODD, while there are shared characteristics, one may qualify for both independently.

While Jane also demonstrates a clinical phenotype similar to autism spectrum disorders, previous testing has ruled out this diagnosis and she does not demonstrate the communication deficits or repetitive behaviors necessary to meet criteria. Since Jane does not display the necessary facial dysmorphology for a diagnosis of FAS, documentation of more than minimal prenatal alcohol exposure is required, which is apparent from review of social services records.

Often, documentation of more than minimal prenatal alcohol exposure is not present, hindering the ability to potentially give the ND-PAE diagnosis. A decision tree for identification of children affected by prenatal alcohol exposure was recently described by Goh et al. (2016) . This decision tree requires a small number of clinically-obtained variables to determine whether an individual is likely to be affected by prenatal alcohol exposure. As part of the current testing, this decision tree is presented in Figure 4 with a highlighted path to indicate data from Jane's case. In her case, there was clear documentation of heavy alcohol exposure in utero, and application of the decision tree yielded an outcome consistent with this documentation. In many cases, where exposure information is not available, application of the decision tree may be useful to rule in or rule out the possibility of alcohol effects.

Decision tree for identification of children affected by prenatal alcohol exposure. Data from the current case are indicated are highlighted in red. Figure adapted from Goh et al. (2016) .

Note: AE = alcohol-exposed, CBCL = Child Behavior Checklist - domains included Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, and Aggressive Behavior. Physical exam for FAS includes measuring whether key facial features are present (palpebral fissure length ≤10 th percentile; philtrum lipometer Score=4 or 5; vermilion border lipometer score=4 or 5). Criteria for FAS diagnoses requires at least two of three KEY facial features (palpebral fissure length ≤10 th percentile; philtrum lipometer Score=4 or 5; vermilion border lipometer score=4 or 5), and presence of head circumference ≤10 th percentile OR height and/or weight ≤10 th percentile. VABS = Vineland Adaptive Behavior Scale, domains included Communication, Socialization, and Daily Living Skills. Physical Exam (extended features) are specified as ptosis and incomplete extension of one or more digits.

DSM-5 Diagnoses

Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure, Other Specified Neurodevelopmental Disorder (315.8, F88) Attention-Deficit/Hyperactivity-Disorder, combined presentation (314.01, F90.0) Specific Learning Disorder with Impairment in Mathematics (315.1, F81.2)

Rule Out: Conduct Disorder, Oppositional Defiant Disorder, Separation Anxiety. These diagnoses are better captured by the alcohol related neurodevelopmental diagnosis, though continued monitoring and targeted intervention is recommended.

Discussion of treatment recommendations

Treatment recommendations with an evidence base for children with heavy prenatal alcohol exposure are scarce; however, this population may respond well to interventions developed for other developmental disorders. Previous efforts have been successful in creating evidence-based interventions in other areas of functioning for children with FASD by modifying existing programs, such as social skills ( O'Connor et al., 2006 ) and math ( Kable et al., 2015 ; Kable et al., 2007 ), which supports the feasibility of adapting interventions to suit the specific needs of affected children. The development of evidence-based interventions for FASD is a critical research need that has been repeatedly documented ( Kalberg & Buckley, 2006 , 2007 ; Premji et al., 2007 ).

Preliminary studies have demonstrated that children with FASD can make significant gains with effective instruction ( Kable et al., 2015 ; Kerns, Macoun, MacSween, Pei, & Hutchison, 2016 ). For example, children with FASD were able to learn a verbal rehearsal strategy that improved their digit span performance ( Loomes, Rasmussen, Pei, Manji, & Andrew, 2008 ). Further, recent studies have found that self-regulation and executive function trainings result in improved parent-reports, inhibitory control, and storytelling ( Nash et al., 2015 ; Wells, Chasnoff, Schmidt, Telford, & Schwartz, 2012 ). Computerized and attention focused interventions have also been moderately efficacious ( Kerns, Macsween, Vander Wekken, & Gruppuso, 2010 ; Pei, Flannigan, Walls, & Rasmussen, 2016 ). Math intervention studies that were developed in concert with the neuropsychological profile associated with prenatal alcohol exposure (Math Interactive Learning Experience, MILE) have demonstrated significant gains in both pilot studies and community-based intervention ( Kable et al., 2015 ; Kable et al., 2007 ). In Jane's case we would recommend this program, given her circumscribed deficits in this area. The MILE intervention focuses on improving math performance within the context of other issues that influence an alcohol-exposed child's ability to learn including emphasizing learning readiness (preparing the environment for optimal performance), individualized pace of instruction, physical and visual aids, active feedback, and meta-cognitive control (encouraging greater reflection in problem solving).

Children with heavy prenatal alcohol exposure are likely to have an especially complex set of factors contributing to educational attainment including higher likelihoods of history of abuse, foster care or adoptive care, and a distinct, yet heterogeneous neurobehavioral profile. As the majority of children with FASD are enrolled in general education classrooms ( Boys et al., 2016 ; Howell et al., 2006 ), it is recommended that these children receive a thorough and comprehensive evaluation to uncover potentially ‘invisible’ special needs that may be missed or misinterpreted to be incorporated into an effective educational plan. A recent study found that approximately 50% of alcohol-exposed children had difficulty in academic functioning ( Boys et al., 2016 ), demonstrating minimal improvement in over 25 years from previous studies ( Streissguth et al., 1991 ; Streissguth et al., 1994 ; Streissguth, Barr, Kogan, & Bookstein, 1997 ).

The heterogeneity of academic, behavioral, and cognitive function in children with FASD makes it exceedingly difficult to create a “one size fits all” academic curriculum. For instance, the range of intellectual function among these children is quite broad, and therefore effective interventions must cater to a wide range of abilities. In addition, programs must understand and address the interplay between cognitive, academic, social, emotional, and behavioral challenges. For example, poor performance may be due to behavioral impulsivity or executive dysfunction, both of which are common deficits in FASD. Other predictors are correlated with inattentive/overactive behaviors in internationally adopted children (which are overrepresented in the sample used in this study) that indicate older age at adoption, longer time in the adoptive home, and smaller family size are associated with greater parent-rated difficulties. Further, these difficulties were associated with poorer reading performance, expressive language, and adoptive family functioning ( Helder, Brooker, Kapitula, Goalen, & Gunnoe, 2016 ).

Assessment of school-based services for children with FASD is a burgeoning area of research. In the classroom, a combination of evidence-based interventions may be the most efficacious, as they can target various areas simultaneously. Since 60–95% of alcohol-exposed children are diagnosed with ADHD ( Fryer, McGee, Matt, Riley, & Mattson, 2007 ; Mattson et al., 2011 ), it may be worthwhile to investigate the feasibility of repurposing existing, empirically supported ADHD interventions or interventions for other populations for use in children with FASD. There are several interventions in which utilizing treatment approaches for other populations (such as ADHD or ASD) have been effectively used for prenatal alcohol exposure, although they generally require considerable modification and individual tailoring based on the unique neurobehavioral profile of alcohol-exposed children. Unfortunately, the availability of interventions has fallen far below the needs of alcohol-exposed children, and many of these programs are still being studied to assess generalizability, feasibility, and efficacy.

Access to Services

Currently, the most common and feasible method of receiving services for an alcohol-related neurodevelopmental disorder is to qualify for services under a different diagnosis, such as intellectual disability or ADHD, or to qualify under a specific catch-all category based on functioning and symptomology. Legal precedents providing services for individuals with intellectual disability, or those requiring similar services, have facilitated access to services. Section 504 plans can help with classroom accommodations, yet fall short of creating an individualized plan and addressing unique needs of the individual ( Senturias, 2014 ).

Individuals with FASD may require services from numerous providers, including primary care, specialist centers, occupational therapy, psychosocial skills training, and educational specialists ( Rogers-Adkinson & Stuart, 2007 ). In general, the coordination between providers, disciplines, and agencies, requires a case manager or social worker to facilitate care. Often these systems of care are referred to as wraparound services that help increase communication and coordination between all parties involved in care (e.g., parents, teachers, mental health professionals, physical/occupational therapists, behavioral therapists, assessment teams, physicians, speech/language, adoption services, foster care services). Wraparound services are not specific to prenatal alcohol exposure and can be utilized for a variety of complex medical or behavioral presentations. In particular for prenatal alcohol exposure, there are several FASD service centers ( McFarlane & Rajani, 2007 ) that provide models for the continued development of resources. However, there is no easy or practical way to standardize the service needs for children, as each child will have unique patterns of deficits and may require a more individualized approach. One study using semi-structured interviews revealed that there were no standardized special education classes that were appropriate for all alcohol-affected children, as each child required individual supports based on their own pattern of functioning ( Autti-Ramo, 2000 ).

It is important to note that prenatal alcohol exposure results in neurological dysfunction and often behavioral and cognitive effects. As is the case with neurodevelopmental disorders, the course of care is not solely focused on full remediation or is curative in nature, but rather emphasizes supports and intervention to build on the strengths of the child, while considering the weaknesses to improve overall function. As the individual grows there are additional concerns and considerations that must be addressed including potential supports for transition to independence, additional contact with high-risk situations, and a widening gap of performance and age-based expectations. A continued holistic approach to consider all aspects of functioning and environment is important to inform effective intervention and high likelihood of positive outcomes.

Summary of the Case

Given Jane's profile of functioning, she was given diagnoses of Neurodevelopmental Disorders Associated with Prenatal Alcohol Exposure (Other Specified Neurodevelopmental Disorder), a specific learning disorder with impairment in math, and ADHD combined presentation, as discussed above. The clinician who provided the assessment also attended the IEP meeting at her school to provide additional support for Jane's parent's request for an IEP and share specific strategies that may be especially beneficial for Jane's behavioral and cognitive outcomes. The IEP meeting consisted of the principal, representatives from special education, current teacher, adoptive mother, and adoption advocate. As is often the case, the clinician provided psychoeducation to the team regarding the effects of prenatal alcohol exposure, as most members had very little training to work with this population. The clinician was able to educate the team and empower the parent in sharing pertinent information regarding Jane's case. This discussion led to the development of a specific and targeted IEP that included particular focus on providing additional time and training on new concepts (repeating new lessons until competency was achieved) and a new behavioral reinforcement schedule (tying the positive reinforcement directly and immediately to a behavior, for example getting a sticker immediately after turning in an assignment). Jane also received specific targeting intervention at home and at school focused on improving her math abilities including tutoring, online math programs, the use of the MILE program as discussed above, and modified assignments to improve her math facts skills before introducing more complex information. Further, she was also given recommendations for ADHD including creating a work environment to reduce distractions, using a reward system, encouraging ongoing collaboration between all parties involved (e.g., teachers, parents, psychiatrists, therapists, tutors, and other providers).

Understanding Jane's full neurobehavioral profile from a comprehensive neuropsychological assessment led to a parsimonious diagnosis and actionable treatment recommendations. Further, this assessment assisted in less punishment and more support for areas in which she struggles (e.g., instead of getting a grade reduction for not turning in homework, creating a new system for keeping track of homework and additional scaffolding for supporting homework completion by breaking assignments into steps). This level of involvement is not often feasible; however, understanding the full profile of functioning and providing additional support to parents and schools results in improved outcomes.

Parent-training with a focus on antecedent-based strategies (rather than consequence based strategies) may be a more effective approach as it has been successful in other neurodevelopmental disabilities. Further, this strategy directly focuses on compensating for weaknesses observed in ND-PAE, for example difficulty with learning from prior experience and self-regulation. Both parent training, in-home behavioral consultation, or other aspects of wraparound services can be helpful for both the teaching of new skills and generalization of progress. Psychoeducation for all parties involved in care, from parents to teachers to mental and medical health providers, is imperative in effective cross discipline communication and overall improved outcomes while considering the holistic nature of factors that can affect functioning (e.g., environment, social stress, other system level issues).

An interagency collaboration suggested several areas for improving outcomes, including: FASD awareness and education in schools, understanding FASD as a comorbid disorder ideally in the context of a medical diagnosis similar to acquired brain injury, FASD specific interventions including collaboration between clinicians and school psychologists, advocacy for children with FASD, conducting a full neuropsychological assessment, and continuing interagency collaboration ( Boys et al., 2016 ). This case study corroborates these findings and provides additional support for continuing assessment and advocacy for this population.

Acknowledgements

Preparation of this paper was supported by the National Institute on Alcohol Abuse and Alcoholism grants U01 AA014834 (Mattson) and F31 AA022261 (Glass). We thank the families and children affected by prenatal alcohol exposure for graciously participating in studies at the Center for Behavioral Teratology at San Diego State University.

Compliance with ethical standards: This article does not contain any studies with human participants or animals performed by the author. The case study is a composite of cases seen by the first author.

Conflict of Interest: The authors declare they have no conflict of interest.

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Teen Cocaine Addiction Case Study: Chloe's Story

This case study of drug addiction can affect anyone – it doesn’t discriminate on the basis of age, gender or background. At Serenity Addiction Centres, our drug detox clinic is open to everyone, and our friendly and welcoming approach is changing the way rehab clinics are helping clients recover from addiction.

We’ve asked former Serenity client, Chloe, to share her experience of drug rehab with Serenity Addiction Centre’s assistance.

Chloe’s Addiction

If you met Chloe today, you would never know about her past. This born and bred London girl is 20 years old, and a flourishing law student with a bright future in the City.

A few years ago though, it seemed as if this straight A student was about to throw away her life, thanks to a  class A drug addiction .

Chloe had a great childhood. By her own admission, school was a breeze for her, with strong academic achievement and social skills making her as successful on the playground as she was in the classroom.

Age 7, Chloe started at a boarding school, and loved having friends around her all the time. With no parents about, Chloe and her friends found themselves invited to house parties. As soon as I could convince people they we 18, they moved on to London’s nightclubs.

It was here where Chloe first came across drugs, and it was a slippery slope to cocaine addiction. She explains: “At 15, I was taking poppers, graduated to MDMA at 16, and then I tried cocaine at our year 13 parties. I got separated from my friends, and found them taking cocaine in a back room. I didn’t want to be left out, so I tried it.” 

Chloe scored straight As in her A levels, and accepted a place at Kings College London to study law. She was introduced to new people, and it seemed that cocaine was available at every place they went. Parties, clubs, and even her new friends were all good sources of a line of cocaine. As a self confessed wild child by this point, Chloe didn’t want to miss out.

The demands of a law degree were high, but so was Chloe’s desire for more cocaine.

Going out almost every night to snort coke, she started to wonder if she was becoming an addict. She spent every penny of the generous allowance from her parents. Chloe spent every penny available on credit cards, and even took on a £2000 bank loan to support her habit.

Chloe estimated that at one point, her addiction had saddled her with more than £13,000 of debt.

Coming out of Addiction Denial

Chloe’s light bulb moment finally came when her best friend, who she shared a flat with, sat her down and asked why they were drifting apart.

Chloe realised that cocaine had become more important to her than her friends, family, and studies. It had to stop. Chloe found the details for Serenity Addiction Centres, and called the same day to ask for help with her addiction.

One thing Chloe particularly appreciated about Serenity Addiction Centres was the flexible approach of the counsellors . They got to know Chloe, listening to her worries, and working out a non-residential rehab plan for her. This allowed her to continue with her studies.

Chloe’s treatment was organised at a clinic not far from her university, allowing her to keep her studies on track, and keeping her life as normal as possible.

Chloe says: “Talking about how I was using cocaine, along with contributing problems from earlier in my life, were a massive help. I didn’t want to be known just as a party girl”.

“If I’d not found Serenity Addiction Centres, there would probably have been a long wait for NHS treatment. Serenity Addiction Centres got the right treatment. Everything was organised with privacy and discretion. I only shared what was happening with my flatmate.”

This level of discretion was really helpful, and the rapid results of her treatment meant that after just three months Chloe felt able to tell her parents what had been happening. 

Life after rehab

It’s amazing that Chloe has now had nearly a year where not taken cocaine, and faced her debts by working part time to repay what she owes. Even better, thanks to Serenity’s fast intervention. Chloe is on course for a 2:1 in her law degree.

If you’re ready to detox? Serenity Addiction Centre’s addiction support team are here to help you find the rehab programme which works for you. Serenity can help you beat your addiction. Gaining control over drugs, allowing you to move on and take back control of your life.

This Drug Addiction Case Study is here so others may identify. Contact us today , and begin your detox journey with Serenity Addiction Centres.

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