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Introduction

Fetal Alcohol Spectrum Disorder (FASD) has long been recognized as a major concern for the development of children. Problems identified include behavioral, social and academic challenges along with self-regulation. There are often comorbid mental health issues such as Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder as well as Substance Abuse Disorders. As they transition to adulthood, they have a much higher risk of being involved in the criminal justice systems and face more challenges with employment. There is a large literature aimed at working with children who have been diagnosed or are suspected of having the disorder (Badry & Pelech, 2011; Bertrand, 2009; Blair, O’Connor, Frankel & Marquardt, 2006; Brown & Bedner, 2004; Ministry for Children and Families British Columbia (MCF), 1999; Rutman & Van Bibber, 2010).

These children are now becoming parents. The child protection systems (CPS) in Canada are facing the challenge of how to determine when these parents should be parenting their own children. FASD is a significant issue for CPS across Canada, although the actual rates are not well established. Indeed, the specific prevalence in the Canadian population, both Aboriginal and non-Aboriginal is poorly established (Pacey, 2010). Under diagnosis remains a substantial concern (Chudely, Conry, Cook, Loock, Rosales & LeBlanc, 2013). It is fairly well established that FASD is a significant concern with children in care and in Aboriginal populations (Tough, 2009). Pacey (2010) in a review of current knowledge indicates that diagnosed FASD children are more likely to be in institutional or foster care. Fuchs, Burnside, Marchenski & Murrary (2005) report on a Manitoba sample that 11% of all children in care and 34.2% of children with disabilities in care have been diagnosed with FASD. Fuchs, Burnside, Reinink & Marchenski (2010) indicate that there is surprisingly little known about how youth who have been in care and been diagnosed with FASD, fare as they transition to adulthood. Yet, they tend to come into care earlier, become permanent wards more quickly and will spend a greater amount of their life in care as compared to other children with disabilities (Fuchs, Burnside, Marchenski & Mudry, 2007).

However, under diagnosis remains a large problem meaning that many parents who have FASD have not been diagnosed. Thus, their parenting problems may well be seen as being something else, particularly a mental health concern (Malbin, 2004).

Virtually no attention has been paid to the question of how to assess parenting capacity of FASD parents who become involved with CPS. Social workers or the courts may order Parenting Capacity Assessments (PCA) with the goal of better understanding the strengths and limitations of the parent. The view is to determine whether the parent is going to be “good enough” to raise their child(ren). However, with this population, the question might be further framed, “Is this parent, along with appropriate supports, capable of being good enough to raise this child or be a significant presence in this child’s life?”

Aunos & Feldman (2007) note that parenting capacity consists of the combination of practical skills, which are directly related to parenting activity. But there are also parallel skills such as problem solving and personal management. An assessment must also look at the environment in which parents function, including their support systems. To be truly effective with this population, PCAs should be sensitive to the cultural context of the parent (Twigg & Hengen, 2009).

The disability view – challenging it

Given the paucity of literature in respect of FASD parents, the next available database relates to parents with emotional, mental or physical disabilities. Researchers in those fields note that there is often a presumptive bias that such parents are quite unlikely to be able to successfully raise their children. As the research emerged, that bias has been found to be false. A large number of such parents are able to meet the needs of their children, although may often require supports. Booth & Booth (1998) found that some of the presumptive biases simply do not hold up to scrutiny, such as the belief that the children will become parentified. They also suggest that assessments are often deficit focused and should, instead, consider a resiliency approach.

When we use the FASD label to describe the parent, we flatten our understanding to that sole dimension. We make the labeling even worse when we stretch it to a First Nations person with FASD. This is a narrowing of the possible understanding of the person reinforicng the presumptive bias of inability as opposed to strength or resiliency. FASD is a spectrum disorder, which, by definition, means that the range of capacity will also exist across a spectrum.

In the same vein, it is wise to remember that First Nations cultures are no more homogenous than any other cultural group (Neckoway, Brownlee & Castellan, 2007, p. 70). . Thus, there is no “First Nations Formula” for PCAs. There is cultural sensitivity to the specific case before an assessor. Different parenting styles exist in different cultures and yield acceptable outcomes for the child (Phoenix & Husain, 2007). Different does not equate to not good enough.

Can interventions with FASD parents work?

In challenging the disability view, one also must accept that interventions can work with at least some of the FASD population. If they cannot, then assessment has reduced utility. The few studies that have been done, have shown that with appropriate intervention and supports, there is reason to believe that many FASD parents would be able to fulfill the requirements of the role (Denys, Rasmussen & Henneveld, 2011; Rasmussen Kully-Martnes, Denys, Badry, Henneveld, Wyper & Grant, 2010). This small literature base suggests that, as in the realm of disability research, there is reason to challenge the presumptive bias that FASD parents would, by definition, be unlikely up to the task.

Abraham (2005) demonstrated that supports for parents with FASD are often done by workers with little formal academic preparation in the area, although most had less formal training (p.71). This may impact outcomes. Needs for parents were identified around adaptive skills and those needed for daily living such as around housing, financial management and transportation (p. 79; see also Rutman & Van Bibber, 2010). With better preparation of support systems, such as seen in the disabilities sector, there may be a greater opportunities for FASD parents. In time, we may have a more thorough understanding of what will differentiate those who are more probable for success as opposed to those who are not.

An effective PCA can assist in identifying these differences. However, following Western approaches, which are concerning from a First Nations perspective, would not be wise. For example, the use of psychometrics faces a number of challenges with this population. To begin with, cognitive development and academic progress may make administration of these tools rather concerning with FASD individuals. Further, the author is unaware of any parenting measures that have norms established for FASD parents or the First Nations population. This makes their utility quite limited. As Bombay, Mathieson & Anisman (2009) show, most mental health measures are based on Western conceptualization of illness and are normalized against white, middle class samples (p.27). The same is largely true of parenting assessment measures.

Approaching the parenting capacity assessment

How then should an assessor approach the question of doing an effective PCA with a parent who has FASD or is suspected of having the disorder? The latter is crucial given that a significant number of people with FASD are not diagnosed (Chudley et al., 2013; Tough, 2009). Assessors should be sensitive to the possibility that the diagnosis might exist when they are presented with a parent having a profile or history consistent with possible FASD. The lack of openness by the assessor to this possibility will mean that a parent is being assessed with a significant void in the data.

There are several good formats for conducting PCAs (Budd, Clark & Connell, 2011; Choate, 2009; Pezzot-Pearce and Pearce, 2004). However, these again have been developed with a view to the broad, more Western population as opposed to either an FASD or Aboriginal parent. Stienhauer (1991) extols us to approach such assessment with a mind towards the least detrimental alternative.

Feldman & Aunos (2010) writing about disabled parents have strongly argued for a functional approach to assessment. The research tells us that FASD parents are likely to have cognitive and adaptive skill deficits (Malbin, 2004). This does not mean that they are absent of parenting skills. They may also have been victimized in their own formative years and lived with instability which can impact their understanding of healthy or at least, good enough parenting.

Many will have grown up in the care system. The state has often proven to not be a particularly good parent and thus, these parents may have maturational or life skill deficits that will be identified using a functional approach. A poignant example of the problems with growing up in the child protection system is seen in the 2005 presentation Wards of the Crown (Cazabon & Schnobb). It shows that the state may not be a better alternative to the parenting available through the parent with supports. Such negative experiences are not unique to Canada. Lemn Sissay (2012) has recently spoken about the challenges of growing up in care in the United Kingdom. Courtney et al., (2011, 2010) have shown that outcomes are poor for children growing up in care in the United States.

These experiences make it hard to engage parents in the assessment process. Such difficulty should not be interpreted as resistance but a natural impact of negative life events during formative years. Further, as Twigg & Hengen (2009) review, First Nations individuals find it hard to connect to traditional mental heath approaches which is where most PCAs are rooted.

The core question – Can this parent raise this child?

The assessment should focus on the core question - can this parent raise this child (Pezzot-Pearce & Pearce, 2004)? In FASD cases, a second question might be added. Can this parent raise this child with supports? It does not need to be done alone. Such thinking is also consistent with the collectivist approach to Aboriginal parenting (Neckoway et al., 2007). It is also consistent with the disabilities literature (Feldman & Aunos, 2010). However, it raises the notion that assessment will need to look at the supports and not just the parent. The FASD parent who has the insight to recognize that they cannot do it alone, and needs supports, should be viewed as possessing a self-insightful strength. They may well be more willing to create a scaffold of support around them. The viability and utility of this is an important consideration that should be central to the assessment.

The label FASD does not inform about parenting capacity. Like many disabilities, FASD impacts exist on a spectrum ranging from rather mild through to quite significant. It is, therefore, the expression of the disorder that matters and how that impacts parenting. In cases where there is not a diagnosis, although it is suspected, a look at the functional capacity of the parent is more informative.

The assessment considers a variety of factors that will impinge on parenting. These can be thought of as including the parent’s historical factors such as developmental history, trauma, education and employment, mental health and addictions and involvement in the child welfare system. Functional assessment would include decision-making, the nature of the relationship with and responsiveness to the child, the ability to manage self and the child, impulse control and financial management. When deficits are identified, consideration is required on the willingness to access and use both formal and informal supports.

The Medicine Wheel can be a useful tool given its cultural relevance and its ability to explore the areas just identified above for assessment. Using this tool, the Aboriginal parents (with or without FASD) may find inquiry of their life and parenting capacity more meaningful. It helps the parent to see how they may be living with their physical and mental health in or out of balance (Twigg & Hengen, 2009).

Parenting is bi-directional. The parent impacts the child and the child impacts the parent (Patterson & Fisher, 2002; Pettit & Ariswalla, 2008). Thus, the parent must be able to engage the child and permit ways for the child to engage the parent. When looking at direct behaviors of the parent with the child, the assessment considers the parent’s ability to read the child’s cues and to respond appropriately. Can the parent see the child at an appropriate developmental level? Can they provide a safe and nurturing environment? Can the parent help the child create meaningful relationships and experiences outside of the family? These might include kinship relationships as well as school, sports or other community activities. Can the parent support the child to acquire the skills needed to move through pre-adult developmental steps?

Risk is to be assessed. This includes poor impulse control that is connected to such things as crime, neglect of the child or other forms of maltreatment. Other risks include addictions, mental health as well as problems with self management including structures and routines that are beneficial to children. Grant, Ernst, Streissguth and Porter (1997) identify that the risks can be challenging, including poor judgment, failing to respond to the needs of the child and not appreciating those needs. Depending upon the nature of the risk, there may be worry arising from bringing into the child’s life people who import risk into the family environment.

No PCA can be done without also considering the very unique needs of each child. As virtually anyone who has parented more than one child will tell you, each one is unique with specific needs. Some children are more demanding. There is the very real possibility that an FASD parent may have an FASD child. Thus, the needs of the child may be higher than might be experienced otherwise. Can the parent manage these specific needs (Pezzot-Pearce & Pearce, 2004)?

There is no window into the behavior of a parent that is better than seeing what happens in the actual interactions with the child. This requires time and should be done in as naturalistic environment as possible. Observations with parents who have FASD should be longer so as to observe a variety of parenting challenges and responses. Initially, the parent may be concerned about the assessor’s presence, but this fades rather quickly in most cases. The point is to see how the parent operates at a functional level (Aunos & Feldman, 2007). As these authors note, the idea of seeing parents in action allows for a competency-based perspective that considers both the risk and protective factors (p. 227). Such an approach also balances the tendency towards a deficiency perspective that has been found to exist with assessment of parents with disabilities (Booth & Booth, 1998). These observations help to compare information from other sources with that which is happening in the actual observed interactions between parent and child.

Not about perfection

The standard that the assessment considers is whether or not the parenting can be good enough in the circumstances. The concept of a parent being good enough was found in the writing of British psychoanalyst Donald Winnicott (1957, 1964). His work raised the idea that perfectionism should not be the basis upon which a parent should be judged. Nor should parents strive to achieve this as it is unattainable. Something less was, in his view, ‘good enough’ to successfully raise a child. The concept again found favour in the work of Bruno Bettellheim in his highly readable parenting guide, A Good Enough Parent (1987). This was a self-help book on raising a child that reinforced the idea that much can be achieved in guiding a child towards adulthood without the parent being focused on perfection.

Parents raised either in foster or group care or in family situations where recovery from the traumas of the Residential Schools or the Sixties Scoop were an active part of the family story, may be less prepared for the role of parent (Mattens, Daily & Hodgson, 1998 as cited in Tait, 2003, p. 87). Generations of parent mentoring are missing. The question of “good enough” must consider that. How can that be managed and still create a “good enough” environment? It is with this perspective that assessment can minimize the risk of extending the oppression of the past into the present circumstances (Blackstock, 2009).

Tait (2003) has identified that there are a number of inter relating factors for mental distress and mental health that link to the impact of residential schools. FASD would be one such legacy. These legacies also impact parenting and family functioning through increased rates of physical and sexual abuse, suicide, mental health issues, family breakdowns and substance abuse and addiction (p.82). If the solutions are seen as removal of the children from the family system, then the intergenerational losses will be compounded and extended.

During both the residential school period and the Sixties Scoop (which went beyond that decade), Aboriginal mothers were deemed unfit to raise their children. Tait (2003) adds that this judgment was also applied to grandmothers looking after their grandchildren. Such an approach sees caregivers as independent actors with the children as opposed to seeing the nature of a collectivistic culture and the ability of the larger family system to care for children, such as can exist in Aboriginal communities. Child protection is typically focused on the primary caregiver although there are some efforts suggesting a broader view as recently published by one authority which says that they should give preference to kinship placements whenever possible (Calgary and Area Child and Family Services, (CFSA), 2013). PCAs should follow local legislation but also policy initiatives such as this that promote family, cultural and community connection. By focusing on sustaining connections, family systems can be supported and the loss of parenting skills from intergenerational traumas can begin the rebuilding process from within the culture (Bombay et al., 2009, p. 87).

As Tait (2003) notes, in the early twentieth century, physical health in Aboriginal communities was heavily impacted by epidemics. This was accompanied with poverty, inadequate nutrition, poor medical care and marginalization (p. 79). This too has impacted the parenting legacies compounding the effects of the residential schools. The Royal Commission on Aboriginal Peoples (RCAP) has clearly documented that these multiple adverse experiences have ongoing impacts on Aboriginal peoples throughout Canada and across generations (RCAP, 1996).

If an assessment does not take into account the present impact of these historical, collective intergenerational traumas, then it fails to fully understand the parent within their true environmental context.

It might also be worth framing Aboriginal parents with FASD as having the disorder layered on top of the intergenerational trauma. Fournier and Crey (1997) have articulated that, in the Sixties Scoop Aboriginal mothers were not measured on cultural determinants of acceptable parenting. Given that there continues to be a void in cultural specific elements to PCAs, this may be continuing.

When problems are identified with parenting capacity, the assessor must ask if they are treatable and / or manageable. The two are different. This might be illustrated this way. An addiction might be treatable through a rehabilitation program whereas a cognitive deficit might be managed through the use of external supports such as extended family involvement or a community support service. In FASD cases, both issues might be present – the need for treatment and management of varying issues. Treatment can be done with various physical and mental health resources while management is done with services through community agencies and extended family.

FASD parents arrive in child protection courts with what can often seem to be challenging histories and many obstacles to successful parenting. It is easy to overwhelm them. This can lead to giving up or a sense that it will never be possible to raise their own children. This can be further compounded if the recommendations arising from a PCA are numerous and onerous and do not reflect what might be treated or managed through resources that are, in particular, rooted within the Aboriginal communities and programs. To overwhelm an FASD parent is to set them up for failure.

Recommendations should take into consideration the motivation of the parent to succeed through learning and supports. In writing recommendations, a key question becomes what is possible within a reasonable period of time. What steps can be taken that will make a difference in parenting? Recommendations that focus on that, are practical, and can be implemented with resources available, will be the most useful.

An assessor, who takes into consideration solutions that may reflect not only the FASD but also the willingness of the extended family and the community to support the parent to meet the needs of the child, offers better hope for a child. Being raised inside the family system seems to offer a child better hope than being raised within the child protection system (Fuchs et al., 2010).

Conclusion

PCAs are an opportunity for an objective assessment of the capacity of a parent with FASD to determine if, and under what circumstances they could parent their child. These assessments are typically done when child protection is involved. Yet, if they are not methodologically sound, they can serve to harm rather than assist. If the parent is seen as incapable merely because of the FASD, or that becomes a part of the presumptive bias, then it will be hard for there to be a useful assessment in which all of the parties can have faith. It is hard for a parent to get an objective assessment if such bias exists.

FASD is a medical condition that is not well understood by many practitioners (Abraham, 2005). It might be argued that it is a specialized area. As Blackstock (2011) notes, many who work in child protection lack good training in key contextual areas that affect many FASD parents, being poverty reduction or substance misuse (p.36). It could well be argued that even fewer professionals working in and around child protection have specialized training in assessing FASD parents, partially because there is no significant training to be had in that area.

A review of the research that could be found on FASD individuals as parents is scarce and does not specifically address this need. Yet, it is well understood that PCAs are important and powerful features of child protection case management (Budd, Clark & Connell, 2011; Choate, 2009; Pezzot-Pearce & Pearce, 2004).

As Blackstock (2011, 2009, 2007) has suggested, child protection has a real risk of acting as a method by which oppressive practices continue with the Aboriginal peoples. A diagnosis of FASD places a person at increased risk given their vulnerabilities. To borrow Blackstock’s term (2011), there is a need for “moral courage” to create an environment in which assessments are done from a depth of understanding that takes into consideration the diagnosis, the functional capacity of the parent, the needs of the child and the profound environmental issues arising from poverty, the history of oppression and its effects. When using an ecological and strengths based approach with FASD parents, a view of what is possible using the strengths of the parent and those who would support the parent. There can be a circle of positive attachment figures for a child that includes the FASD parent and other primary figures. This will spread the load and still provide a secure base for the child. Such thinking is consistent with an Aboriginal view of the role of family but runs counter to how child protection systems typically think of how parenting is to be done. In her presentation, Sims (2010) has shown that children can do well within a caregiving system.

Research has shown that children who grow up in the child protection systems remain at high risk for poor outcomes (Courtney et al., 2011; Courtney et al., 2010; Doyle, 2008). This should act as a modifier in thinking that children may be better off away from family. That might be true in cases where the risks cannot be managed. But this clearly suggests that such a consideration should be an essential element to these assessments.

A further consideration is that, if ways are not found to keep families intact within the Aboriginal communities, and children are removed from parental care because of FASD, then a further generation will be without parent mentoring from within their family system. This superimposes further intergenerational transmission of parenting deficits. A conscious and purposeful effort to reverse that trend requires that PCAs look at areas of strength that will allow FASD parents and their supports to raise the children. While it will not always be possible, seeing such a solution, as a natural option to be considered, is different than present PCA literature might suggest (Budd, Clark and Connell, 2011; Choate, 2009; Pezzot-Pearce and Pearce, 2004).

Area for future direction

It is apparent that the research base for looking at crucial issues around FASD parents is absent. There has been no review that the author is aware of that shows how FASD parents do over time; the quality of their parenting based on the severity of the disorder; no systemic view of best practices for assessment and no review of the ways in which FASD parents fare within the child protection systems. Thus, this review extrapolates the PCA literature in general and that which relates to other parents with disabilities.

Real efforts are needed to develop culturally sensitive approaches to assessing parents within the First Nations communities. The Medicine Wheel is one possibility although there is an absence of research that helps to know if this accurately identifies areas of strength and concern within parenting capacity. When combined with FASD, even less is known about culturally sensitive and effective mechanisms for assuring that useful, objective and accurate assessments are being conducted.