by Emma Mears
“You have a chance to offer your professional expertise, which is of high value. You get to contribute your time and make an impact in your community and repair inequalities that we are becoming more aware of in terms of privilege, class, and race. You get to learn and connect to somebody in a way that is deeply meaningful.”
A Home Within Volunteer Therapist Mary Haake discovered in college that she wanted to work with people—maybe, she says, it’s because both her parents were educators who were passionate about improving the lives of kids and teens in her hometown of Redding, CA. After attending community college, Mary went to UC Santa Cruz. “I don’t think I understood at the time what it meant to do psychotherapy, so I was naive in a way,” Mary says with a laugh. “But I liked studying and thinking about psychology, which led me to apply and get into a PhD program in clinical psychology at UMass Amherst.”
At UMass, Mary gained a passion for family therapy, an interest she pursued in her postdoctoral internship at the Philadelphia Child Guidance Clinic. “I got to work with a diverse group of families, many affected by poverty and racism. We learned about empowering parents to support their kids in new ways. It was pretty exciting.”
Back in California, Mary got a job at Kaiser Permanente in Oakland, where she worked in the child and family service section of their psychiatry department for 26 years. During her time there, she was introduced to A Home Within. “Someone came to a meeting at Kaiser to present about the concept of long-term psychotherapy to heal the traumas of the foster care system, which I found really interesting,” Mary says. “I could see that these kids really needed long-term psychotherapy as a support, so I got excited about this opportunity and made some client referrals to A Home Within.”
Nine years ago, Mary transitioned to private practice, and decided to make the commitment to join A Home Within. “I have been working with an adult who was raised in foster care,” Mary says, “and it’s been an incredible experience. It’s incredible on so many levels, which is why I wanted to get involved as a Clinical Director to see if we could build and expand the opportunities for clients.” And she did, becoming Clinical Director of the Alameda County chapter last year.
As a Clinical Director, Mary has gotten to learn more about A Home Within and build connections. “It’s been great because I’ve been able to get acquainted with what is going on within the Alameda County chapter,” she says. “We currently have 18 volunteers including four consultation group leaders who provide ongoing support for our 14 therapists. The majority of the therapists have been working with their clients for six years or longer, so I have gotten to see how the work really is ongoing.”
A lot of the work at AHW is made possible through the consultation groups, weekly meetings during which volunteer clinicians can get support around their cases. Mary says the groups “are entirely essential. Anybody who has been through the foster care system has had to deal with instability and pain, so the group is essential to hold everything together. It is really rewarding to do this work with the group because they are there in the difficult moments. Many in the consultation groups have been working together for many years.”
Mary sees continuity as critical for success in both private practice and for the AHW client. “The A Home Within model is so exceptional because it is such a unique clinical opportunity for both the therapist and client,” says Mary. “I learn a lot in my consultation group. It’s a key part of my private practice experience. Especially this year dealing with the pandemic, to have this ongoing group to share experiences with has been so helpful. It’s been extremely valuable to know others in the field and their work. I am able to make referrals for clients with confidence to people I really trust.”
If you are able to volunteer with AHW, you have the opportunity to have an extended relationship with a client who could not otherwise have access to ongoing therapy. Mary says, “You have a chance to offer your professional expertise, which is of high value. You get to contribute your time and make an impact in your community and repair inequalities that we are becoming more aware of in terms of privilege, class, and race. You get to learn and connect to somebody in a way that is deeply meaningful.”
About Emma Mears
Emma is currently an intern at A Home Within. She was born and raised in Oakland, CA, and is a third-year Health and Society student at Cal Poly San Luis Obispo.
“It is common for A Home Within clients to be unsure if we are going to be there for them long-term because they have made connections and lost them in the past. So just the idea that we are offering to be their therapists for as long as they want—that it’s in their control, not ours—is so unique.”
When Vanessa Hernandez was assigned her A Home Within client over four years ago, she was met with some hesitancy. Anna* was 13 at the time and had already had several therapists. Many foster youth, needing free services or a sliding scale, are matched with interns, as Anna was. Once the internship ends, the therapeutic relationship also ends. Anna had made a good connection with the last therapist she had. “So once the counselor left, she didn’t really want to start the process again,” Vanessa says. “The starts and stops can be difficult.”
Fortunately, Vanessa managed to convince Anna to give her a chance. “The idea that I could tell her that I was going to be her counselor until she decided to not come to counseling anymore was really important,” says Vanessa. They both had to navigate getting to know each other. “Teenagers put you through it. I’m just another adult to them,” she says. “They think ‘Should I trust you? Why should I trust you?’ Teenagers can see right through you. And that’s what I like—you don’t get an automatic pass. You have to work through it. Once you do make that connection, there is so much you can do.”
In order to build that connection, Vanessa got creative. She and Anna started by setting up various board games during each session. Once they landed on Monopoly, they stuck with it. “We played Monopoly for probably four years straight. It’s a long game. We would play Monopoly and just talk to each other,” says Vanessa. “And at the end of the session I would take a picture of the board so we knew our place. We had a running score. The idea that something continued every week was important. Sometimes we would set up the game and not even play. We would just talk. But Anna always knew what to expect. There was a sense of permanency there.”
Vanessa receives support for her work with her client in her weekly A Home Within consultation group with other Volunteer Clinicians. “Consultation groups give us a chance to talk about our cases, and they are pretty complicated cases. It’s really nice to get input from these really great therapists,” she says. “Being a therapist, especially in private practice, can be so isolating. Even more so with the pandemic. The consultation groups have continued virtually and it has been so helpful to discuss what we are doing with all of our clients, even beyond A Home Within. What we do in our groups has helped me become a better therapist.”
Vanessa has had to adjust her practices during the pandemic. “The work that I need to do now is more with the family to support Anna. I see her mother, but I also still have time in place for my client,” says Vanessa. At this point she feels like she is “a fixture in their family, and I have been for some time. I have been involved with big life decisions regarding her life. You don’t usually get this experience with your clients unless you see them for a long time.”
Vanessa hopes the adaptations therapists and clients have had to make during the pandemic serve to broaden the idea of what therapy can be. “It doesn’t just need to be going to the therapist’s office,” she says. “We can see each other through FaceTime or other online methods, going to backyards, and even going on walks. Being flexible means we can reach more people from different groups.”
Vanessa’s volunteer work with A Home Within has been valuable to her client and herself. “The most unique part about A Home Within is that it is pro-bono and for however long the client wants,” she says. “It is common for A Home Within clients to be unsure if we are going to be there for them long-term because they have made connections and lost them in the past. So just the idea that we are offering to be their therapists for as long as they want—that it’s in their control, not ours—is so unique.”
About Vanessa:
Vanessa Hernandez grew up in Pittsburg, California, she moved to Oakland over 20 years ago and has remained there since. Vanessa attended Saint Mary’s University in Moraga, California for both her undergraduate degree in Organizational Psychology and her master’s in counseling.
*The name and some identifying details have been changed to protect the client’s privacy.
by Emma Mears
“My work with A Home Within is one of the most important parts of my private practice.”
Sarah Campbell didn’t always know she wanted to work with adolescents. Following the birth of her second child, Sarah began exploring a career change, preferring not to return to her previous job in marketing. While in therapy to help her through postpartum depression, Sarah found the experience so transformative that she decided to go to graduate school to become a therapist herself. Eager to help others as she had been helped, Sarah still didn’t think she’d want to work with teens.
While getting her M.A. in Counseling Psychology at Saint Mary’s College in Moraga, California, Sarah began studying how to help new moms go through postpartum, including body work through yoga. “You can’t ignore the body when dealing with the mind,” Sarah says. “Movement is important to work through what’s going on.”
The whole time she was in graduate school, Sarah thought postpartum work would be her focus. “I read every paper and textbook on the topic,” she says. “I even wrote my thesis on supporting postpartum mood and anxiety disorders with yoga and cognitive behavioral therapy, which was actually what had helped me.”
But towards the end of her program, her focus shifted as her practicum required that she complete internship hours with people under the age of 18. Sarah got an internship at a high school wellness center and ended up loving working with teens— and adolescents have been the majority of her clients since. Her internship supervisor introduced her to A Home Within.
After completing her license in 2012, Sarah opened her private practice, and began working with her AHW client soon after. She immediately found a community at AHW, which she greatly appreciated. “Being in private practice, it is so important to have a network of colleagues,” she says. “It is really invaluable to have this network that you trust and can consult with.”
Sarah has found her consultation group to be essential to her work with AHW. By conferring with fellow mental health professionals, she gains insights into her work with her AHW client as well as with her other clients.
“What’s great about the consultation groups is that there are four therapists and a mentor,” Sarah says. “Everyone has a different approach. It’s really a creative consultation where everyone is super supportive, and it bleeds into my work with other clients— whether it’s a way of thinking, a question, or an approach to dealing with a situation, it often applies in some way to all of my clients.”
With a growing number of young people seeking therapy from AHW—there are now over 20 young people on our waitlist in Alameda County alone— AHW is seeking additional volunteers from around the country for all of our chapters.
Sarah urges other mental health clinicians to take this unique opportunity to volunteer with A Home Within. “It is really an honor and a privilege to be able to do this work,” Sarah says. “It is really grounding as a therapist to know that every week I have that hour with my client. It’s really amazing to get to know someone and work with them during a huge period of their life for however long it takes.”
In her private practice, Sarah works with many young people whose parents have pushed them into therapy. “If a child wants to be there,” says Sarah, “if they choose it themselves, it makes a difference as a therapist. And that’s how it is with A Home Within—the young person really shows up every week.”
Sarah and her AHW client have now been working together for nine years. “I’ve known this person since they were a kid,” she says, “and now they are an adult.”
Thanks to the community AHW has opened up for her, as well as the rewarding relationship with her client, Sarah sees herself continuing for as long as her client would like. “My work with A Home Within is one of the most important parts of my private practice,” she says.
We at A Home Within are deeply grateful to Sarah and our other wonderful volunteers for making A Home Within possible.
About Emma Mears
Emma is currently an intern at A Home Within. She was born and raised in Oakland, CA, and is a third-year Health and Society student at Cal Poly San Luis Obispo.
by Saralyn Ruff (Associate Professor of Psychology, University of San Francisco) and Deanna Linville (Associate Professor & Research Scientist of Mental Health, University of Oregon)
The big idea
In the first two months of the pandemic, more than half of former foster children lost their jobs and nearly 40% experienced precarious living situations or homelessless, according to a survey of 127 former foster children between the ages of 18 and 26 that we conducted in May and June of 2020.
They were among the estimated 20,000 people in foster care who are “emancipated” each year when they age out of the system, beginning as young as 18. These young adults typically lose most of the support the government provides foster children – such as caseworker support and access to health care and housing.
Most of the people we surveyed were college students. Like most former foster youth going to college in the spring of 2020, they did not have a stable living situation or family to go home to when campuses across the country shut down. Many described how the resilience they developed in foster care made it easier to withstand these new challenges.
“Being in foster care taught me how to survive, which makes living through a pandemic a little easier,” one told us.
Others shared concerns that underscored how challenges facing former foster children go far beyond what’s going on during the COVID-19 pandemic.
“I wish that there was more support for us older foster children who want to do more with our lives, who truly want to break the stigma around being in foster care,” one participant told us. “At the same time, we are never truly given the [help] we need to make all of that possible.”
We also heard concerns about children who remain in the problem-prone foster care system: “I can’t stop thinking/worrying about the kids that are stuck in foster homes they do not like/are unfit,” one survey participant wrote.
Others shared concerns about children and teens still in foster care becoming less likely to be reunited with their relatives, and more likely to lose contact with them, due to travel restrictions and social distancing.
Why it matters
Even when the economy is strong and there’s no global calamity, these young adults experience financial hardships. They need to support themselves earlier than their peers, which can result in housing and food insecurity and interfere with their schooling. Only 4% of former foster children graduate from college, compared with more than one-third of their peers.
And when the pandemic struck, it made things a lot worse for former foster children.
Millions of students will return to college campuses in the fall of 2021 for the first time in about 18 months. Among them will be many former foster children, including some who are not ready to resume in-person instruction after a tumultuous time in their lives. Although often resilient, we believe these young people will require support from their colleges and universities.
What’s next
We are digging deeper into this data to learn more about the experiences of the college students who completed this survey to see what kinds of aid and support were the most helpful for young people left in the lurch during lockdowns.
by Emily Finch
Emily Finch (she/her/hers) is a former member of Oregon Foster Youth Connection (OFYC), and participates in a Portland support group facilitated by A Home Within. She has been writing poetry since she was 9 years old, the age she entered foster care.
We are excited to share a beautiful poem by her, A Home Within.
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By John Stirling, MD & Karen Zilberstein, MSW, LICSW
The past two decades have seen revolutionary advances in understanding the neurodevelopmental consequences of childhood trauma (Nemeroff, 2016; Teicher & Samson, 2016). As awareness has spread, trauma-informed practices have been urged on medical practitioners (Oral et al., 2016) and child welfare agencies (Hanson & Lang, 2016). Evidence-based, trauma-specific therapies have been widely promoted and adopted (Blaustein & Kinniburgh, 2010; Cohen et al., 2016; Lanktree & Briere, 2013).
Childhood maltreatment often co-occurs with parental substance abuse and prenatal alcohol exposure, which are also known to affect children’s neurodevelopment (Coggins et al., 2007; Walsh et al., 2003). Understanding of the global effects of prenatal alcohol exposure lags behind that of toxic stress, and little research has explored the relationship between the two. However, there are considerable and often confusing similarities between the clinical manifestations of toxic stress and prenatal alcohol exposure, and their interactions can be significant. This paper evaluates the similarities, differences, and interactions between the two conditions and the concomitant implications for diagnosis and intervention.
Trauma and Neurodevelopment
Traumatic experience, especially when chronic or repeated, alters neurophysiology. Changes are actuated primarily through the release of stress hormones at various sensitive periods in a child’s development (Shonkoff et al., 2012; Teicher & Samson, 2016). Faced with an acute threat, the brain’s neuroendocrine stress response system (hypopthalamic-pituitary-adrenal axis, or HPAA) prioritizes safety by temporarily activating brain areas and physiologic systems that help the organism react to danger. When the threat passes and the environment returns to normal, these previously useful adaptations need to be reversed. Such plasticity, or resilience, is one of the hallmarks of a healthy brain.
Chronic or repeated (“toxic”) stress puts a strain on this system, especially when adult caregivers do not provide soothing interactions that help regulate the child’s psychophysiological state. The brain’s adaptation to chronic or repeated stress can produce hypervigilance, constant hyperarousal, and hyperreactivity. The chronically aroused brain, prioritizing quick and decisive responses, devotes less attention to developing cognitive functions and controls (Marusak et al., 2015). Input from sensory systems may be muted, presumably to decrease distraction and distress (Shimada et al. 2015; Teicher & Samson, 2016). Such learned stress responses, however, often prove maladaptive in classrooms or other normative environments. While it is tempting to think about these changes as evidence of damage, it may be more useful to recognize them as protective adaptations (Elbers et al., 2017; Teicher & Samson, 2016).
Numerous studies examine how the experience of childhood maltreatment and resultant toxic stress appear to impact the growth and structure of the growing brain (Hart & Rubia, 2012; Marusak et al., 2015; Kavanuagh et al., 2017; Paquola et al., 2016; Teicher & Samson, 2016). When alterations in brain structure arise, they consistently appear to reduce the size, connectivity, and functioning of a few prime areas (see Table 1): the prefrontal cortex, anterior cortex, hippocampus, amygdala, corpus callosum, and cerebellum. These regions control executive functions, working memory, attention, inhibition, and the processing of emotions.
Findings from clinical studies of neurocognitive functioning map closely with data gathered through brain imaging of trauma victims (Hart & Rubia, 2012; Herringa et al., 2013; Paquola et al., 2016; Teicher & Samson, 2016) (see Table 2). Identified difficulties include lowered IQ and deficits in attention, language, abstract reasoning, visual-spatial skills, and inhibition. Memory can be diminished, as can the ability to regulate emotion and attention. Robust findings suggest that childhood trauma interferes with the development of executive functions (Ford, 2009; Gabowitz et al., 2008; McCrory et al., 2010). Hyperaroused, inattentive, and impulsive children tend to miscue social and other situations, contributing to relational difficulties. Reduced connectivity between neurons has been linked with anxiety, depression, and low IQ (Teicher & Samson, 2016).
Trauma is clinically associated with difficulties with mood and behavior (see Table 2) (Ford, 2009; Gabowitz et al., 2008; Goslin et al, 2013). In young children, trauma adaptations may manifest as symptoms of regression and anxiety. As children age and cognitive and behavioral demands increase, anxiety, depression, aggression, withdrawal, dissociation, learning problems, hyperactivity, social difficulties, and somatic complaints become prominent. High incidences of ADHD, PTSD, and bipolar disorder occur in adulthood (Felitti et al., 1998; Ford, 2009; Sugaya et al., 2012).
Fetal Alcohol and Neurodevelopment
Only in recent decades have the toxic effects of prenatal alcohol exposure (PAE) been studied with scientific rigor. Fetal alcohol syndrome (FAS), a combination of distinctive phenotypical traits including growth inhibition and neurodevelopmental impairments, was first described by Jones and Smith (1973). Children with FAS exhibit characteristic facial dysmorphologies, growth deficits, and congenital anomalies involving other organ systems. Cognitive, emotional, and behavioral impairments are common (Mattson et al., 2019).
It has subsequently been recognized that individuals exposed in utero to alcohol, even those who do not display the distinctive facial features and poor growth seen with FAS, tend to suffer similar, persisting neurodevelopmental impairments (Murawski et al., 2015; Mattson et al., 2001). When neurodevelopmental deficits are the only manifestation of toxic exposure, which is the case in an estimated nine out of 10 children with FASD, the disorder is harder to recognize (Bakhireva et al., 2018; Green et al., 2009; Mattson et al., 2019; May et al., 2009).
Though the broad term FASD is still commonly used in the literature to refer to all disorders related to PAE, FASDs with neurodevelopmental features appear in the most recent Diagnostic and Statistical Manual, 5th Edition, or DSM–5 (APA, 2013) under the more specific sobriquet “Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (NDPAE).” The new diagnosis focuses on the importance of alcohol-associated neurologic impairments. Diagnosis of ND-PAE requires demonstration of neurocognitive, self-regulatory, and executive function deficits in a child with known exposure to alcohol in utero. Though including children with FAS, diagnosis of ND-PAE does not depend on demonstrating any phenotypic criteria.
Ethyl alcohol is a neurotoxin, which can affect neuroreceptors and neurohormonal modulation at every stage of the brain’s development (Boschen & Klintsova, 2017, Fidalgo et al., 2017). Brain imaging conducted on individuals with ND-PAE illuminates widespread alterations to neural anatomy (see Table 1). Researchers studying both animal and human subjects conclude that fetal alcohol exposure decreases the brain’s overall size, with alterations in the basal ganglia, caudate nucleus, prefrontal cortex, temporal and parietal lobes, and cerebellum (Henry et al., 2007; Mattson et al., 2019; Wilhoit et al., 2017). Functionally, widespread atypical activity and disorganization of network connectivity have been noted (Hoyme et al., 2016; Mattson et al., 2019). Reduction in grey matter and stunted myelination of sensory and motor pathways also occur (Hoyme et al., 2016). Abnormalities have been observed in the corpus callosum, including decrease in size and alterations in shape and volume (Mattson et al., 2001; Wilhoit et al., 2017). In the human hippocampus, volume asymmetries exceed those in control children (Mattson et al., 2001).
Corresponding behavioral and performance deficits are observed clinically (compare Tables 1 and 2). As might be expected from the DSM-5 criteria, deficits have been described in cognitive function (memory, intellect, reasoning, information processing), selfregulation (sensory integration, regulating behavior, inhibiting responses), and executive function (following directions, social skills, learning, attention) as well as in speech and language, vision and hearing
problems, and motor function (Chasnoff et al., 2015; Hoyme et al., 2016; Mattson et al., 2019; Wilhoit et al., 2017). Approximately 70%–90% of children with FASD exhibit problems with attention, hyperactivity, and impulse control (Green et al., 2009; Greenbaum et al., 2009; Mattson et al., 2001; Wilhoit et al., 2017). It has been suggested that the damage done to the prefrontal cortex underlies ADHD seen after alcohol exposure (Louth et al., 2016).
Children with ND-PAE may miss social cues and struggle to show affection to caretakers (Wilhoit, et al., 2017), behavior which can lead to the misdiagnosis of an autistic spectrum disorder (ASD; Mukherjee et al., 2011; Stevens et al., 2013). As social learning requires both the pattern recognition skills of the right cerebral hemisphere and the analytic talent of the left, it may be hypothesized that children with inadequate development of the corpus callosum would find social learning challenging.
Because of their many challenges, children with ND-PAE are at risk for secondary pathology. Acquired psychiatric problems include depression and anxiety (Mattson, et al., 2001; Wilhoit et al., 2017). Impulsivity, difficulty following directions, and diminished understanding of consequences can lead to rule-breaking and trouble with the law (Mattson et al., 2001). Limited adaptive living skills may make achieving independence difficult.
Combined Effects of FASD and Trauma
Only a few studies try to probe the symptoms of children with PAE who have also experienced trauma and neglect, and their results must be interpreted cautiously (see Price et al., 2017, for a review). The most extensive study by Henry et al. (2007) compared 274 children aged 6–16 years old, 97% of whom had suffered severe trauma and 40% who had also been diagnosed with FASD and found that the combined group scored statistically lower on intelligence, attention, memory, receptive, and expressive language. Parents and teachers also rated the trauma/FASD group as showing more oppositional, social, impulsive, and inattentive symptoms than the trauma alone group. Coggins et al. (2007) studied 573 children aged 6–12 diagnosed with FASD and found that a high percentage had experienced abuse and neglect. They evaluated children’s social communication abilities and concluded that the combination of FASD and maltreatment conspire to robustly compromise children’s abilities. Koponen et al. (2009) studied 38 children in foster care with a mean age of 10 who had been exposed in utero to alcohol and found that traumatic experiences aggravated social, emotional, and neurocognitive problems. Mukherjee et al., in 2019, compared data on 99 subjects and concluded that prenatal alcohol exposure inflicted more neurodevelopmental damage than neglect. The authors cautioned against misattributing children’s symptoms to neglect and poor parenting quality when the primary damage may arise instead from prenatal alcohol exposure.
The limited research conducted thus far suggests that PAE and trauma, when combined, lead to worse symptoms than would be expected in either condition alone. A child whose stress response system and executive functioning abilities are diminished possesses fewer tools with which to organize and regulate behavioral responses to stress. Resilience is compromised by both conditions.
Challenges in Applying Research Findings
Although researchers have attempted to delineate the independent and combined effects of both prenatal toxins and postnatal trauma, results of the many studies and meta-analyses must be viewed cautiously. Studies are often troubled by small sample sizes, differences in populations, lack of consistent measures, and other problems.
Controlling for confounding variables, though of crucial importance, proves especially difficult. One of the greatest challenges researchers face is separating the effects of pre-existing neurodevelopmental difficulties from those of subsequent maltreatment. Parental alcohol abuse is both a diagnostic necessity for ND-PAE and a major association with child maltreatment (Walsh et al., 2003). Yet when Kavanaugh et al. (2018) reviewed studies investigating neurocognitive impairments in maltreated youth, only three out of 24 published reports specifically mention excluding individuals with FASD, leaving open the possibility that a proportion of subjects in the studies of childhood trauma suffered from undetected ND-PAE, potentially confounding results. Conversely, traumatic postnatal experiences can be a significant confounding factor in studies purporting to demonstrate effects of early alcohol exposure.
Fortunately, animal models provide independent evidence for the neurobiological effects of both prenatal alcohol and of analogues to childhood maltreatment. Rodents exposed to alcohol in a controlled environment predictably develop altered neural architecture, endocrine dysfunction, and behavioral changes analogous to those seen in humans with ND-PAE (Mattson et al., 2019; Fish et al., 2018; Hellemans, et al., 2008). Laboratory animals, known not to have been exposed to alcohol in utero, also show alterations in response systems and brain regions affecting learning and executive functioning when subjected to early stress (Flandreau & Toth, 2018, Teicher et al., 2006), producing behaviors analogous to PTSD. Animal studies help give confidence that, despite the much greater difficulties in drawing valid conclusions from human studies, fetal alcohol exposure does target many of the same structures affected by traumatic stress, potentially impairing resilience.
Diagnostic Issues
Given their similar target organs and presentations, the effects of trauma can be difficult to separate from those associated with ND-PAE. As always, awareness is the first step, as differential diagnosis is only as good as the variety of conditions considered. Before attributing a given dysfunction to the exclusive effects of trauma, it is important to consider the role played by coexisting neurodevelopmental disorders, especially ND-PAE. In seeking to understand the effects of childhood trauma, assessors should find out as much as possible about the child’s baseline level of function before the trauma and view behaviors in this context.
Both alterations in brain structure wrought by trauma and those seen after PAE affect parts of the brain that regulate stress, but underlying mechanisms differ. Alcohol affects the developing fetus as a teratogen, damaging structures and neural networks. Alcohol’s effects appear to be more widespread and severe than trauma’s (Henry et al., 2007; Price et al., 2017; Mukherjee et al., 2019). Trauma’s alterations typically begin after birth, as the brain reorganizes itself to contend with environmental circumstances. The brain’s innate ability to learn and change in response to new experiences and stimuli remains intact (Belsky & Pluess, 2009; Hart, 2011). In fact, some evidence suggests that children who are most susceptible to brain changes as a result of adversity may also be more amenable to the reparative effects of positive experience (Belsky & Pluess, 2009). Therapeutic interventions depend on such ongoing plasticity.
Evidence suggests that the damage inflicted by alcohol is more permanent and less responsive to treatment than are the changes wrought by early trauma (Murawski et al., 2015; Young et al., 2016). When the brain’s ability to learn and change is organically impaired, response to standard therapies is affected. Effective interventions cannot be implemented without considering the independent and combined consequences of trauma and ND-PAE.
Evidence-based recommendations for assessment of trauma’s effects cast a wide net, but often not wide enough to catch the interplay with alcohol-related neurodevelopmental disorders. Time and attention are given to determining symptoms common to trauma along cognitive, relational, affective, behavioral, and somatic domains. They include examining inaccurate and maladaptive thinking, social difficulties, anxiety, depression, anger, and self-regulation (as well as their severe manifestations in suicidality, substance abuse, or psychosis), dissociation, flashbacks, traumatic triggers, and avoidance (Cohen et al., 2016; Ford, 2009; Wherry, 2014). In the few instances that published recommendations urge assessment of executive functioning and neurocognitive skills, impairments are generally viewed as sequelae of maltreatment. Gabowitz et al. (2008), in describing the neurocognitive assessment of a 10-year-old boy with a history of severe emotional and physical neglect, who presents with dissociation and impairments in executive functioning, organizing information, integrating details, inhibition, and inflexibility, conclude that
If a trauma framework were not applied to this case, it is likely that Zachary would be labeled with a diagnosis that captured his specific behavioral manifestations (e.g., Attention Deficit Disorder, Oppositional Defiant Disorder), and treatment would be targeted to his isolated symptoms (aggression/impulsivity, difficulty concentrating, not following directions), without attention to their etiologies or functions…. Zachary’s early traumatic experiences have resulted in neuropsychological deficits in his executive functioning. (p. 172)
As cogent as these comments are, it is perhaps ironic that the authors do not describe attempts to screen for prenatal alcohol exposure, which is also well known to impair executive function.
One of the difficult diagnostic questions concerns whether and to what degree observed symptoms precede or result from trauma. Trauma on its own certainly contributes to neurocognitive difficulties. At the same time, neurodevelopmental impairments such as ND-PAE are seen both to intensify the risk of maltreatment and to heighten sensitivity to stress, increasing incidence and severity of PTSD (Finzi-Dottan et al., 2006). Conversely, high IQ, executive functioning, and verbal ability tend to boost resilience, decreasing behavior problems after traumatic experiences (Goslin et al., 2013; Horn et al., 2018). Given this bidirectional interaction, it can be difficult to recognize whether a given symptom arises from trauma-related maladaptation, preexisting neurocognitive difficulties, or a combination of both. Signs of neurodevelopmental difficulties, including those associated with alcohol exposure, may be mistaken for trauma or the existence of trauma overlooked in children with significant neurocognitive impairments.
Research on, and recognition of, FASDs is still evolving, and many professionals have difficulty with diagnosis and treatment. Studies indicate that missed and misdiagnoses are common (Chasnoff et al., 2015; May et al., 2018; Woolgar & Baldock, 2015) and that families perceive lack of support from their medical providers (Coons et al., 2018; Domeij et al., 2018; Helgesson et al., 2018). This lack is all the more surprising as FASDs are common: It is estimated that from 3% to 10% of the general United States population may qualify for the diagnosis. In the child welfare population, the incidence rises to 17%, reflecting the interaction between ND-PAE and trauma (May et al., 2018; Young et al., 2016; Zarnegar et al., 2016). Among the population presenting for mental health treatment, percentages of FASDs are likely to be greater. Given both the frequent absence of distinctive physical characteristics and the difficulties obtaining a reliable history of maternal alcohol consumption, as well as the frequent co-occurrence of alcohol exposure with subsequent abuse and neglect, it is likely that even these high numbers are underestimations. The condition likely remains undetected in many children.
Diagnosis is further complicated by the fact that ND-PAE is a heterogeneous disorder. Damage and symptomatology vary widely, depending on timing, duration, and severity of exposure as well as genetic vulnerabilities. The DSM triad of neurocognitive impairment, poor self-regulation, and lack of executive function may also manifest differently through the lifespan and result in other medical and psychiatric diagnoses. In a meta-analysis of behavioral symptoms in children with FASD diagnoses, Popova et al. (2016) identified 428 additional diagnoses describing medical, mental, neurocognitive, and behavioral disorders. The most prevalent neurocognitive and behavioral conditions included impulsivity (90.7% pooled prevalence), receptive language disorder (81.8%), and expressive language disorder (76.2%).
What is not clear from Popova’s meta-analysis is how many subjects in the pooled studies also experienced in utero exposure to other toxic substances, or whether the children experienced subsequent childhood adversity and to what degree. Nicotine, opiates, cocaine, and methamphetamines have been associated with decreased fetal growth and later with children’s impulsivity, attention, learning, and executive functioning difficulties (Behnke et al., 2013).
Concomitant use of drugs and alcohol, which occurs in many instances, complicates attribution of a specific problem to one toxin or another. Also unclear is whether subsequent exposure to trauma might have affected the range or severity of symptoms noted in the studies.
Confidently diagnosing FASDs is complicated as there are at present no laboratory tests that could objectively confirm alcohol exposure in utero, and parents fearing stigma and guilt may not provide an accurate history of alcohol intake (Murawski et al., 2015). Especially for children in the child welfare system, prenatal histories may not be known (Bakhireva et al., 2018; Murawski, et al., 2015). As a result, as Young et al. (2016) note,
When children with ADHD and associated FASD are separated from their birth mothers and moved through the care system, they are often inaccurately identified as having insecure or disorganized attachment disorders, instead of being accurately identified as having developmental, emotional, and behavioral difficulties attributed to PAE. (p. 9)
Interpretation of symptoms can be biased by clinicians’ familiarity with some disorders (notably attachment and PTSD) and not others (Coons et al., 2018; Domeij et al., 2018; Woolgar & Baldock, 2015; Young et al., 2016). The combined and cascading effects of FASD with maltreatment make it particularly hard to recognize FASD as an underlying impairment and identify it as a factor in treatment (Zarnegar et al., 2016).
Assessment involves piecing together the diagnosis through evaluation of symptoms and signs, taking a careful history of prenatal exposures, and ruling out other disorders that might cause similar symptoms.
Treatment
A healthy brain that has adapted to a stressful environment can be expected to be more resilient than one whose coping mechanisms have been compromised by prenatal toxins. The extent to which traumatized children with comorbid FASD possess the neurocognitive capacity to partake in trauma treatment remains under-researched. As neurocognitive difficulties influence how well children understand, retain, and apply interventions, trauma-informed treatments need to consider children’s neurocognitive abilities and the types of interventions in which they can best engage. In their study of foster children with FASD, Koponen et al. (2009) found that children whose diagnoses of FASD had been missed exhibited more behavior problems than diagnosed children, perhaps because their symptoms were misunderstood and appropriate interventions not offered.
The current clinical emphasis on trauma has led some clinicians to recommend that, when potential comorbidities exist, trauma should be treated first (Griffin et al., 2011). However, impaired resilience associated with an FASD can mean slower progress and more challenges in therapy, and increased stress and frustration for caregivers whose expectations do not take the child’s limitations into account (Koponen et al., 2009; Paintner et al., 2012). When two conditions are so closely related, it would be a mistake to treat either preferentially.
Behavioral medications prescribed in FASDs or trauma tend to target presenting symptoms, demonstrating significant, if quite variable, success in controlling ADHD, anxiety, and depression. Specific evidence for medications’ clinical efficacy in the presence of ND-PAE remains rudimentary. While one literature review found that stimulants worked to decrease symptoms in 88% of studied FASD patients (Paintner et al., 2012), another systematic review found little evidence to support the use of psychotropic medications in FASDs (Mela et al., 2018). Indeed, increased behavioral disturbances have been reported after medication (Murawski et al., 2015; Young et al., 2016). Neurobiological differences seen after prenatal exposure to alcohol may make those individuals respond differently to symptom-directed medication.
As individuals with FASDs tend to break rules and can find themselves in legal trouble (Mattson et al., 2001), child welfare and legal professionals would benefit from increased knowledge of ND-PAE. When youth’s underlying disabilities go unrecognized, they are expected to understand and perform better than they are able. They may be given punitive or impractical sentences and service plans that set them up for failure. Institutions and professionals serving maltreated youngsters should become informed about the types of supportive and ameliorative interventions FASD youth require.
Conclusions
Because prenatal alcohol exposure alters the same parts of the brain as trauma, its presence is often obscured and overshadowed by a history of adversity. Yet overlooking its effects on a child’s presentation and symptoms would be a mistake. Alcohol damages tissues and brain structures more widely and permanently than does trauma, affecting how a child learns, grows, and reacts to stress (Mattson et al., 2019; Murawski et al., 2015; Wihoit et al., 2017). As alcohol diminishes structures in the brain that confer resilience, children with FASDs who are subsequently exposed to traumatic experiences will be less prepared to deal with them and suffer greater and longer-lasting consequences.
Since children subject to maltreatment show high degrees of comorbid FASDs (Coggins et al., 2007; Koponen et al., 2009), professionals who specialize in trauma treatment and evaluation should become aware of FASDs and routinely screen for them in children presenting with neurocognitive deficits. By recognizing and assessing for alcohol exposure, professionals will gain useful information to guide and improve clinical, legal, and child welfare services.
Much remains unknown about the combined effects of FASD and trauma, as well as the types of interventions best suited to support and treat individuals with dual exposure. Longitudinal research is needed that can track many aspects of neurodevelopment over time, beginning in the prenatal period. Studies should include controls as well as children affected singly and doubly by FASDs and trauma. Research is also needed to determine how maltreated children with FASDs respond to current interventions in clinical, legal, and child welfare arenas, and what further interventions are needed to improve their functioning.
About the Authors
John Stirling, MD, is a pediatrician who has served as a medical consultant in child abuse and foster care for Santa Clara County in San Jose, California, Stanford Children’s Hospital and Rady Children’s Hospital in San Diego. He is a regional champion for the American Academy of Pediatrics’ Regional Education and Awareness Liaison Network on Fetal Alcohol Spectrum Disorders.
Karen Zilberstein, MSW, LICSW, is Clinical Director for A Home Within and specializes in the treatment of youth who have experienced trauma and foster care. An author and speaker, she has recently published a narrative nonfiction book Parenting Under Pressure: Struggling to Raise Children in an Unequal America, which won two Indie book awards.
By Karen Zilberstein
August 25, 2020
Originally posted in Mad in America
As the country confronts the coronavirus crisis and the ways it has exposed racism and inequality, it is time for the mental health field to look inwards and reckon with its own shortcomings. Similar to other American institutions and disciplines, racial and socioeconomic inequalities tend to be replicated in the accessibility and appropriateness of treatments offered to vulnerable individuals and families.
Numerous disparities exist in service provision and outcomes for children and families of color. Across the country, communities with high proportions of people of color are more likely to be situated in mental health deserts lacking high quality care. Compared to white people, they are more likely to lack or lose health insurance, which restricts their ability to access services. When clients from nonwhite ethnic groups begin psychotherapy, they are less likely to trust and remain in treatment, despite higher exposure to racism, trauma, and other adversities that are known contributors to emotional difficulties. Whereas a high proportion of distressed European Americans engage mental health services, fewer than a third of African, Latinx, and Asian Americans do so.
Reasons for the disparities abound, including clinician biases and assessment instruments that are not culturally sensitive. Standardized measures and interview protocols often do not account for ways different ethnic groups express distress, leading to either an over exaggeration or underreporting of symptoms. Asian Americans, who can be tentative about disclosing thoughts and feelings, may find their suffering overlooked and appropriate treatments not offered. Conversely, Black and Latinx youth are more likely than their white peers with similar difficulties to be pathologized and diagnosed with conduct difficulties or severe mental illness rather than traumatic reactions, learning difficulties, or other treatable conditions. As a consequence, they are more likely to receive punitive rather than ameliorative interventions.
Even when appropriate assessments occur, children and families may encounter interventions that do not adequately recognize the difficulties they face. Experiences of racism and discrimination are too often overlooked by white clinicians and their traumatic impact left unstated and unaddressed. Despite evidence that experiencing racial violence, disparagement, and/or discrimination serve as risk factors for numerous physical and mental health difficulties, neither standard trauma screens nor the popular Adverse Childhood Experiences screening tool asks about experiences of racism as potential traumas or adverse experiences. Without adequate acknowledgement of the impact of racism on mental health, treatments will continue to overlook this prime and important factor.
Not only is a comprehensive understanding of and attention to treating racial trauma absent from many therapies, so too are interventions that reflect diverse cultures. Despite attempts to improve cultural competence, only a handful of treatments, practiced in few locales, weave indigenous methods of assessment and healing into their protocols. In many cultures, healing occurs in spiritual and communal realms, not in the private offices of practitioners. Fellowship and the collective expression of emotion through prayer, singing, and praise assume therapeutic functions in the Black church. Connection to and harmony with the land and cosmology bestow comfort and resilience to the Inuit people of the Canadian Arctic.
Part of the reason that not enough alternative treatments have been created is because western psychotherapies draw heavily on individualistic cultures and modes of thought. The most commonly offered treatment approaches in American mental health facilities are individual psychotherapy, cognitive behavioral psychotherapy, group psychotherapy, and psychotropic medication. Those therapies base their interventions on ideas of health and development that view the rectification of difficulties as primarily personal or family responsibilities, even when the circumstances that tip a person into distress result from inequality, racism, poverty, or other adversities.
Thus, instead of addressing structural inequities head on, interventions focus on their sequelae: managing stress, regulating emotions, and improving relationships. Families and individuals are expected to be resilient and self-sufficient, or to work on becoming so. Society holds them responsible for coping with whatever adversity gets thrown their way.
The mental health field’s emphasis on individual coping can inadvertently contribute to inequities. Researchers studying low-income African American youth in rural Georgia found that the effort required to beat the odds inflicted a cost. Youngsters high in self-control and competence, who showed social-emotional resiliency, also exhibited substantial markers of poor metabolic health. Persevering through poor schools, rampant poverty, discrimination, and inadequate supports precipitated physiological stress. When current mental health treatments ask youth facing the highest hurdles and fewest resources to strive the hardest, the results appear mixed.
The individualistic bent that dominates modern psychotherapies burdens individuals with managing environmental risks that could be better solved by government, civic institutions, and advocacy. Providing families with adequate income, safe neighborhoods, greenspaces, and quality schools has been shown to increase the well-being and achievement of children. Yet psychotherapists are rarely trained in tools to engage or create services that could reduce structural inequities. More often, mental health treatment is viewed as a separate service offered to individuals or families rather than part and parcel of a coordinated remedy.
Reducing disparities and increasing treatment options for clients from marginalized groups must begin by naming and making more visible the prejudices and omissions that exist in current treatments and assessment methods. Psychotherapists need to examine their own biases about poverty, race, racism, and individual modes of healing, and determine their fit for different populations. Clinicians must also ask about and validate clients’ experiences of racism, microaggressions, and cultural insensitivities both inside and outside of the consulting room. For those whose mental health difficulties derive from the offshoots of racism and structural inequities, treatment may need to include ways to reconnect individuals and groups to their culture, strengthen community supports, aid with racial identity development, and encourage resistance and collective struggle.
The mental health field needs to shift focus from primarily examining and strengthening personal and family factors underlying health and well-being to include social and environmental determinants. Assessments should include an examination of the sociopolitical realms in which clients live, with an ear to discerning environmental risk and protective factors. Interventions should not only emphasize skill building and changes to the self, but also consider the benefits of altering a person’s circumstances.
Psychotherapists should consider it part of their role to help clients advocate for health insurance, social programs, and opportunities, as well as abating the discrimination and structural barriers they face. To that end, clinical education must include more training in macro skills that help build the supports, policies, and community infrastructures under-served clients need. Mental health workers can also build backing for programs and policies by calling out the damaging consequences of economic hardship, racial discrimination, and other types of inequality, and the importance of reducing those risks.
The advancement of environmental change could begin with institutions that serve individuals and families, such as courts, child welfare agencies, schools, religious centers, and doctors’ offices. Clinicians should do more to educate those entities about the mental health needs of their clients and work with them to institute the types of programs and care that would best benefit the individuals and families they serve. Partnerships with neighborhood institutions could provide communal sources of healing and build culturally congruent rituals and supports. As important referral sources to mental health care, schools, doctors, courts, and other institutions should also demand that local mental health centers institute treatments and services that reflect the needs and backgrounds of the clients in their communities.
In order to create and deliver more culturally and socioeconomically competent interventions, increased efforts should be made to cultivate the wisdom, experience, and social capital of researchers and clinicians from diverse backgrounds. According to studies conducted by the U.S. Census Bureau and APA, the psychology workforce remains heavily white, although rising numbers of black and Latinx workers are entering the field. Particularly important will be the recruitment of leaders and innovators from communities which are currently ill-served who can bring fresh perspectives.
Inequality in mental health and society will only cease after enough people, both within and outside of the field, speak up, demand better, and work together on solutions.
Join Kristin, from Mental Health News Radio, as she speaks with Reed Connell, Executive Director, and Deanna Linville, Director of Clinical Programs, at A Home Within, which helps provide free therapy for current and previous foster youth. As Reed Connell states, A Home Within’s therapists are all part of a ‘community of hundreds of therapists nationwide who volunteer to provide one on one therapy to current and former foster youth for as long as necessary.’ In this podcast, they explain their organization and discuss how they are personally and professionally navigating the use of their passion for helping foster youth receive stable and undisrupted therapy, therapy that they will not ‘age-out’ of. They explain how the organization also helps support the community of their therapists nationwide.
Reed Connell, Executive Director of A Home Within, has spent nearly 20 years working in foster care, mental health, housing, and special education settings and has developed a sophisticated knowledge of childrenʼs programs and policy development. Reed has worked with statewide and national coalitions to design, pass, and implement a range of important children’s legislation, and has worked with a range of nonprofit organizations and government agencies on resource, program, and capacity development. In 2014, Reed co-founded Social Change Partners, LLC to support nonprofits and government agencies in meeting the needs of children and families. Reed also works with a range of mental health systems change efforts, including Breaking Barriers and The California Children’s Trust. Reed holds an MSW degree from UC Berkeley with a concentration in Management and Planning.
Deanna Linville, currently Director of Clinical Programs at A Home Within, is a licensed Marriage and Family Therapist in the state of Oregon and an AAMFT approved supervisor. She has two decades of experience providing direct mental health care, clinical supervision, and training as well as conducting clinical research. Linville joined A Home Within in June 2020 to work as the program clinical director offering her clinical and research consultation services to clinical directors, volunteers, and staff. Her professional experiences to date inspire and inform her clinical research and allow her to stay on the cutting edge of best practices for training mental health professionals to provide ethical and culturally responsive care. Linville earned her MS and Ph.D. degrees at Virginia Tech in Marriage and Family Therapy as well as completed a 12-month doctoral fellowship at the Chicago Center for Family Health, where she gained specialized training and experience working in collaborative family healthcare settings. She has published over forty manuscripts as well as developed and tested numerous clinical interventions aimed to reduce health disparities, prevent eating disorders, and promote family wellness. Linville also works at the University of Oregon as an associate professor in the Couples and Family Therapy MS program.
BY DEANNA LINVILLE, FELICIA GUTIERREZ, SARALYN RUFF, REED CONNELL AND ELIZA BLACKORBY
The Imprint has recently published dozens of articles exploring the impact of the COVID-19 pandemic on foster youth, and how they perceive and participate in this country’s current reckoning with systemic and institutional racism. It is clear that young people are at the nexus of a set of intersecting crises – most of which have been decades, even centuries, in the making, and only one of which is “novel.”
The pandemic has brought unprecedented stress and anxiety, isolation and economic devastation, all while undermining healthy coping mechanisms. Health disparities that already existed are exacerbated as there are differential impacts along lines of race and class. For example, the ability to maintain social distancing and access healthcare is a privilege directly affected by housing environment, occupation and socioeconomic standing. People of color are more likely to have little choice but to show up to work, directly increasing their risk of contracting the disease and spreading it to their families.
Therefore, it is no surprise that foster youth and families are going to be disproportionately affected as well. A survey from The Field Center for Children’s Policy, Practice, and Research found that the majority of foster youth surveyed in April 2020 reported COVID-19 had adversely affected their mental health, with 56% reporting clinically significant levels of anxiety or depression.
This was before young people were confronted with the footage of George Floyd’s murder. Millions took to the streets – foster youth as well – despite the pandemic, making clear that they acutely feel the pervasive and corrosive effects of racism and injustice.
Former foster youth recognized and decried their own experience of the police. In a Letter to Black Foster Youth, writer and speaker Sade Daniels described “the intimate nature in which we Black foster youth have been hyper-aware and subjected to the presence of police in our lives.”
Of course, the current protesting is a demand to deal with systemic injustices that are interwoven into the fabric of who we are as a nation. The overrepresentation of youth of color in foster care is understood to both reflect and manifest systemic racism. Racial injustices in the implementation of child welfare systems result in more removals, longer stays, and troubling foster care experiences for children of color.
The intersection of the COVID and racial injustice pandemics will have lasting consequences for marginalized and oppressed communities in the United States – foster youth among them. Whether trauma arises from oppression in the community, families having inadequate support, or structural racism in our systems, young people will need proactive and sustained support to live, grow and thrive.
Yet, only a small minority of foster children ever receive mental health services, and youth of color are the least likely. Access and continuity of care are undermined through a set of structural barriers – insufficient provider capacity, logistical challenges and administrative dysfunction. And when youth leave or age out of care, they often lose access to any services they were receiving. Given these and other persistent health disparities, it is no surprise that in the midst of an unprecedented crisis, a person’s race, ethnicity and income define the quality and intensity of their suffering, and whether they get any help at all.
The writer James Baldwin once said, “Not everything that is faced can be changed, but nothing can be changed unless it is faced.” There are two hard truths that America’s child welfare systems must face, and then correct:
Systemic racism is present in child welfare. Systems that consistently achieve a result are performing exactly as they are designed. Change them. All first responders can be trained to handle mental health conditions and to become aware of their own implicit racial biases. Abandon racist structures – from the accessibility of healthcare infrastructure to diagnosis and eligibility criteria that pathologize individuals as a precondition for care. Build a workforce that is diverse on every axis from lived experiences to race to sexual orientation to healthcare approach. Recognize that the combination of the pandemics will have generational effects – and accept the challenge of building generational solutions, over the long term.
Our mental health investment is not close enough. We must ramp up our mental health infrastructure and make it sustainable. Demand investment, innovation and care coordination. This starts with our mental health training programs. Mental health professionals should be trained and incentivized to collaborate across professions and to be first responders so that they are intervening with mental health crises versus relying almost exclusively on police. Make mental health services widely accessible and inclusive. Embrace the challenge of making telehealth work. Constantly cultivate cultural competencies among professionals through ongoing conversations and collective actions.
Over the past several weeks, young people have demonstrated that they can and will make themselves heard – whether in the streets of Minneapolis or in the pages of The Imprint. We must hear them, believe them and act. We must hold each other accountable, examine our own insecurities, and leverage what power and privilege we have to change systems, heal communities, and heal hearts. We must remember what we collectively do now will affect and define us for years to come.
Deanna Linville, Felicia Gutierrez, Saralyn Ruff, Reed Connell and Eliza Blackorby are all staff at the nonprofit A Home Within.