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This September 9th marks 19 years since the first International FASD Awareness Day. Building awareness is multi-faceted and, for long-time advocates of FASD prevention, it can seem that we take two steps forward and one step back.

We asked four members of our Network Action Team on FASD Prevention (pNAT) to reflect on the work they have done over the years in their community of Victoria, BC. They bring perspectives on how practice approaches, policy and research intersect to build effective FASD prevention efforts within the larger goal of supporting the health of women and families in general.

Many people, including health professionals, believe that there is a greater negative impact from opioid exposure rather than alcohol exposure. The current opioid crisis provides us with a unique opportunity for FASD prevention.
Lenora Marcellus — Associate Professor of Nursing, University of Victoria

I have had the opportunity over many years to work with Neonatal Intensive Care Unit teams related to supporting infants experiencing withdrawal from opioids. This issue has actually continued to grow related to the prescription opioid epidemic and fentanyl crisis that is impacting many communities, including here in British Columbia where the Provincial Medical Health Officer declared a public health emergency in 2016 in response to the rise in drug overdoses and deaths. What continues to surprise me in this work is how the issue of prenatal alcohol exposure rarely, if ever, comes into the conversation. Many people, including health professionals, believe that there is a greater negative impact from opioid exposure rather than alcohol exposure. The current opioid crisis provides us with a unique opportunity for FASD prevention . The strategies for supporting women during pregnancy, many developed by members of the pNAT, have been demonstrated in research to be effective, no matter the substance. I encourage you to partner with women, advocates and professionals in your community to highlight the importance of FASD prevention within the many conversations that are taking place about opioid use during pregnancy across Canada and beyond.

The proof is in – these kinds of wraparound programs that join a FASD-informed approach, with being culturally safe, trauma-informed and women-centred are successful and make a significant difference.
Amanda Seymour – Programming and Practice – Coordinator, HerWay Home

HerWay Home’s 5th Anniversary was earlier this year and I’ve been reflecting on how far the program has come since the visioning and advocacy done by community members leading to its opening in 2013. We have had the privilege of working with over 220 women and being allowed into their lives and that of their families. We have seen the impressive strides and successes the women have made and witnessed their love for and connection with their children. I’ve also reflected on how much more society needs to do. To prevent FASD along with the myriad harms from substance use and ongoing violence and trauma, we must address all the social determinants of health. Women report a positive change in their lives due to their connection with other women in the program, the support, trust and respect they receive from staff and the access to practical supports, health care and counselling. When I look forward to the next 5-10 years I would like to see programs like this one be available in many communities on Vancouver Island where I live, across BC and across Canada. The proof is in – these kinds of wraparound programs that join a FASD-informed approach, with being culturally safe, trauma-informed and women-centred are successful and make a significant difference. Women are able to reduce or abstain from substance use, improve their mental health and keep their children or see them returned to their care when they receive non-judgemental, harm reduction supports and tangible, practical help.

[We now have] … a set of Evaluation Maps to provide guidance and tools for developing, implementing and evaluating FASD-related programs (www.fasd-evaluation.ca).
Deborah Rutman – Principal and Co-Founder, Nota Bene Consulting Group & Adjunct Associate Professor, School of Social Work, University of Victoria

As a researcher and program evaluator, I feel immensely privileged to be able to learn about and report on the incredible work undertaken by staff at diverse FASD prevention programs and to hear women’s stories and experiences, including about what a tremendous difference these wrap-around programs such as HerWay Home make to women and their families. For me, one of the exciting opportunities – and one of the challenges – of evaluating FASD prevention programs is depicting the complexities associated with FASD and FASD-related programming: complexities in terms of the inter-related issues that women and families struggle with; complexities in terms of the range of services and program activities that matter to women; and complexities in terms of the myriad program outcomes that, as evaluators, it is important to document, including: women feeling safe and not judged; women having improved basic needs support, nutrition and safe housing; healthy births; reduced child welfare involvement; increased mother-child connection; abstinence/reduced or safer substance use; and women’s sense of connection and hope. Several years ago, our Nota Bene team, partnering with Nancy and with lots of input from pNAT members, developed a set of Evaluation Maps to provide guidance and tools for developing, implementing and evaluating FASD-related programs. Currently, with funding from the Public Health Agency of Canada and in partnership with eight inspiring programs across the country, our team is undertaking the Co-Creating Evidence study: a ‘first in Canada’ national evaluation of wrap-around programs that work with pregnant or recently parenting women with substance use and other complex issues. We have just completed our first round of data collection at all eight sites and we look forward to sharing our findings with NAT members – and beyond – in the coming months.

It so gratifying that for a decade now, we in Canada have been able to meet virtually in this pNAT to share ideas and identify ways to collaborate on research, practice and policy related to alcohol and FASD prevention.
Nancy Poole – Researcher and Knowledge Translation – Director, Centre of Excellence for Women’s Health

Every time International FASD Day comes around, I think both of the tremendous work people are doing on FASD prevention and how much there still is to do. I am so lucky to have colleagues like Lenora, Deborah and Amanda who are committed to FASD prevention in my own city! We get together over dinner fairly regularly to talk about how our work fits together, and how we can actively work together in various combinations to advance FASD prevention research, practice and policy. In particular, we have been able to lend lots of support to the establishment and ongoing enhancement of programming at HerWay Home. Amanda, Deborah and Lenora have also been core members in our national work on FASD prevention where we link and advance the work on research, evaluation, practice and policy through the Network Action Team on FASD Prevention (pNAT) that is funded by the CanFASD Research Network. It so gratifying that for a decade now, we in Canada have been able to meet virtually in this pNAT to share ideas and identify ways to collaborate on research, practice and policy related to alcohol and FASD prevention .

Service providers and FASD prevention advocates are well aware of the intersections of trauma, substance use, and mental health issues as first described by researchers like Lisa Najavits (Najavits, Weiss, & Shaw, 1997). Research from the Women and Co-occurring Disorders and Violence study substantiated what many understood intuitively – that women with substance use problems facing complex life issues are best served through multi-leveled, integrated service models that are trauma-informed, gender-specific, and holistic (Amaro, Chernoff, Brown, Arévalo, & Gatz, 2007; Brown & Melchior, 2008).

There is an upcoming opportunity to learn more about applying these approaches to FASD prevention and care in a webinar on April 18th at 9:00 am MST. The CSS Learning Series webinar as part of their FASD Learning Series will feature speakers Candice Sutterfield, Lakeland Centre for FASD, and Dr. Peter Choate, Assistant Professor of Social Work at Mount Royal University and clinical supervisor for the Alberta College of Registered Social Workers. They will address both a prevention and supports & services perspective. Sign up here: http://csslearningseries.ca/trauma-informed-fasd-prevention-and-care-registration-2/

Programs in Canada, like Breaking the Cycle and HerWay Home, currently offer integrated programs for/with pregnant and parenting women with substance use issues. Their program frameworks are trauma- and FASD-informed and they offer substance use treatment/support programming as well as needed social services and referrals at a single access point. Program evaluation findings show that relationship building is the key component benefiting women’s growth and supporting the mother-child relationship long-term. (See their evaluations here: Breaking the Cycle and HerWay Home).

In a very recent study undertaken in Ontario, findings from interviews with women participating in integrated programs, described qualities of a therapeutic relationship that helped women improve emotional regulation and executive functioning (Milligan, Usher, & Urbanoski, 2017). Therapeutic relationships that incorporate trust, care, positive regard and a non-punitive attitude can create a safe attachment from which women can apply effective problem solving in all areas of their lives.

Sign up for the webinar and see these earlier posts for more information:

The Mother-Child Study: Evaluating Treatments for Substance-Using Women, March 18, 2015

HerWay Home Program for Pregnant Women and New Mothers in Victoria, BC, February 12, 2013

REFERENCES

Amaro, H., Chernoff, M., Brown, V., Arévalo, S., & Gatz, M. (2007). Does integrated trauma-informed substance abuse treatment increase treatment retention? Journal of Community Psychology, 35(7), 845-862.

Brown, V. B., & Melchior, L. A. (2008). Women with co-occuring disorders (COD): Treatment settings and service needs. Journal of Psychoactive Drugs, SARC SUPPL 5, 365-385.

Milligan, K., Usher, A. M., & Urbanoski, K. A. (2017). Supporting pregnant and parenting women with substance-related problems by addressing emotion regulation and executive function needs. Addiction Research & Theory, 25(3), 251-261. doi:10.1080/16066359.2016.1259617

Najavits, L. M., Weiss, R. D., & Shaw, S. R. (1997). The link between substance abuse and posttraumatic stress disorder in women. A research review. The American Journal On Addictions / American Academy Of Psychiatrists In Alcoholism And Addictions, 6(4), 273-283.

Many women who have FASD are able to benefit from tailored support on substance use problems. Audrey McFarlane, Executive Director of Lakeland Centre for FASD in Cold Lake AB recently shared strategies for working on FASD prevention with women who have FASD themselves. One of the LCFASD programs, the 2nd Floor Women’s Recovery Centre, provides residential treatment exclusively to women. She explained how programs can better support women who have FASD.

Challenges

Because of the possible neuro-behavioural and physical health issues associated with FASD, working with women living with FASD may pose particular challenges for the service provider due to:

  • Limited understanding of how their body works and how or why to use birth control;
  • Limited understanding of how to get housing, money and to keep themselves safe;
  • Physical health issues, such as diabetes, STDs, vision, hearing and dental;
  • Limited ability to envision the future;
  • Inability to link actions to consequences, which makes them more likely to be connected to the justice system and to have many children not in their care with multiple partners.

Strategies

McFarlane says that these and other challenges mean it often takes longer to see the benefits of supports. Yet, there are a number of strategies that have proven successful.

  • Take a family alcohol history and ask each woman, specifically, if she has a diagnosis of FASD. Woman will tell you if they do, but are often not even asked.
  • Make suggestions in key areas where they can agree or disagree rather than using client-generated approaches.
  • Prioritize building a relationship so that the woman will come back for support as needed. Reframe returning to treatment as a positive, not a negative.
  • Expect to spend more time on basic life skills and necessities. She may not have connection to family or social services. This means treatment needs to be longer.
  • Approaches that work best include solution-focused counselling, physical activities, positive touch, relaxation, and connections that develop a sense of belonging, like volunteering and cultural practices.

Resources

Here are a number of resources on trauma-informed and FASD-informed approaches for working with women living with FASD.

FASD Informed

2 Reports on Substance Using Women with FASD and FASD Prevention: Voices of Women and Perspectives of Providers, prepared by Deborah Rudman

Evaluation of FASD Prevention and FASD Support Programs website

FASD Informed Approach by Mary Mueller, RN, Waterloo Region Public Health and Emergency Services

FASD Informed Practice for Community Based Programs, College of New Caledonia

Working with Women Who May Have FASD Themselves – Webinar View SlidesRecording

Trauma Informed

Pregnancy, Alcohol, and Trauma-informed Practice, The Prevention Conversation

Trauma-informed Approaches to FASD Prevention – Webinar View SlidesRecording

Trauma-Informed Practice Resource List, Centre of Excellence for Women’s Health

_________________________

For more on this topic, see earlier posts:

WEBINAR JUNE 23 – WORKING WITH PREGNANT AND PARENTING WOMEN: LEARNINGS FROM HERWAY HOME, June 16, 2016

NEW CURRICULUM FOR FASD INFORMED PRACTICE, August 1, 2016

THE MOTHER-CHILD STUDY: EVALUATING TREATMENTS FOR SUBSTANCE-USING WOMEN, March 18, 2015

FACT SHEET ON SUPPORTING WOMEN WITH FASD IN RESIDENTIAL SUBSTANCE ABUSE TREATMENT, April 22, 2013

TRAUMA MATTERS: GUIDELINES FOR TRAUMA‐INFORMED PRACTICES IN WOMEN’S SUBSTANCE USE SERVICES, April 17, 2013

 

ACEs_Original

Adverse childhood experiences (ACEs) is a term that describes potentially traumatic events that can have lasting negative effects on health and well-being. Research has shown a clear connection between ACEs on alcohol use and misuse in adults.

An emerging area of research also suggests that a history of childhood stressors, such as physical, sexual, and emotional abuse, may influence alcohol use among pregnant women.

In a recent study, researchers used data from the 2010 Nevada Behavioral Risk Factor Surveillance System to learn more about this relationship. They found a dose–response relationship between ACEs and alcohol use during pregnancy that remained even after controlling for pre-pregnancy drinking and other known factors that influence drinking during pregnancy.

This study contributes to a growing body of research demonstrating that factors affecting alcohol use during pregnancy begin long before pregnancy.

It also suggests the importance of initiatives and movements such as ‘trauma-informed’ practice and their application to FASD prevention. Learn more about trauma-informed practice, alcohol, and pregnancy use on the Coalescing on Women and Substance use website.

For more on this topic, see earlier blog posts:

5_preganancy

References

Astley, S.J., et al. (2000). Fetal Alcohol Syndrome (FAS) primary prevention through FAS Diagnosis: II. A comprehensive profile of 80 birth mothers of children with FAS. Alcohol and Alcoholism,  35(5): p. 509-519. [Free full text]

Choi, K.W., Abler, L.A., Watt, M.H., Eaton, L.A., Kalichman, S.C., Skinner, D., Pieterse, D., and Sikkema, K.J. (2014) Drinking before and after pregnancy recognition among South African women: the moderating role of traumatic experiences. BMC Pregnancy and Childbirth, 14: 97. [Free full text]

Chung, E. K., Nurmohamed, L., Mathew, L., Elo, I. T., Coyne, J. C., & Culhane, J. F. (2010). Risky health behaviors among mothers-to-be: The impact of adverse childhood experiences. Academic Pediatrics, 10(4): 245–251. [Free full text]

Frankenberger, D.J., Clements-Nolle, K., Yang, W. (2015). The Association between Adverse Childhood Experiences and Alcohol Use during Pregnancy in a Representative Sample of Adult Women. Women’s Health Issues (epub ahead of print). [Abstract]

Nelson, D. B., Uscher-Pines, L., Staples, S. R., & Ann Grisso, J. (2010). Childhood violence and behavioral effects among urban pregnant women. Journal of Women’s Health, 19(6): 1177–1183. [Abstract]

Skagerstrom, J., Chang, G., & Nilsen, P. (2011). Predictors of drinking during pregnancy: A systematic review. Journal of Women’s Health, 20(6):901–913. [Free full text]

FASDInformedPracticeFinalVersionSeptember9-2013_pdf

FASD informed practice can include:

  • An awareness that FASD (diagnosed and undiagnosed) is a reality for many individuals involved with a variety of community-based programs
  • A strong theoretical and practical understanding of the traits, characteristics, barriers, and needs of those affected by FASD
  • A willingness on the part of program staff, including administration, reception, and frontline workers, to participate in ongoing FASD education and training initiatives
  • Agency policies that accommodate the unique needs of individuals living with FASD in order to create a program that works for all participants
  • A respectful and individualized approach to service delivery that recognizes individual strengths

This guide from the College of New Caledonia is designed to assist programs in providing FASD-informed services and supports. The approaches discussed were developed from evidence-based research and from the practical experience of individuals working with women and their families who may be living with FASD.

The guide includes sections on promoting dialogue about alcohol and drug use during pregnancy, contraception, trauma-informed practice, effective group facilitation, strategies for individual support, and examples of exercises that can be used in group programming.

FASD Informed Practice for Community Based Programs can be downloaded from the College of New Caledonia website here.

For more about FASD-informed work at the College of New Caledonia, see an earlier posts:

 

 

Pages from trauma-matters-final

Over the past several years, the impacts of trauma and the interrelationships between trauma and women’s substance use have been well-identified by both research and clinical practice.

Recently, the Ontario Drug Treatment Funding Program Trauma and Substance Use project team released guidelines to support organizations that provide substance use treatment services for women. The guidelines are intended to help service providers understand the interconnections of trauma and substance use and to provide improved care for substance-involved women who have experienced trauma.

The guidelines identify six core principles for trauma‐informed practice: acknowledgment, safety, trustworthiness, choice and control, relational/collaborative approaches, and strengths-based empowerment.

The guidelines also take a look at trauma and its connection to mothering and family relationships. The authors comment:

“Substance-involved women who have experienced trauma may also be mothers, or be pregnant. Many have needs related to their mothering role when they seek help with their substance use concerns. For
these women, concerns about their children and their role as mothers can play a critical part in their recovery and be a powerful catalyst for change.

Hard data on substance use, mothering, and pregnancy are somewhat limited because many mothers fear negative or punitive consequences if they disclose their substance use concerns; however, research
indicates that up to 70% of women who attend substance use programs have children.

Although there are sensitive and caring mother-centered programs in Canada, “there are vast gaps in the availability and accessibility of these services, depending on the required level of care, parenting status,
and the severity of health and social problems.” “(p. 87)

Trauma Matters: Guidelines for trauma‐informed practices in women’s substance use services can be downloaded here as well as from the Jean Tweed Centre, the Evidence Exchange Network, and the Ontario Federation of Community Mental Health and Addiction Programs.

For more on women’s substance use and trauma, see Trauma-informed care for women in Canada (July 11, 2011).

Overview: Four Levels of FASD Prevention

Information Sheet: What Men Can Do To Prevent FASD

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