Fetal Alcohol Spectrum Disorders In Foster and Adopted
Traumatized Children:
Recognizing the Symptoms; Learning Effective Interventions
Lois A. Pessolano Ehrmann PhD, LPC, CAC- Diplomate
Registered ATTACh Therapist/ EMDR (EMDRIA) Clinician
The Individual and Family CHOICES Program
2214 Atherton Street, Suite 4
State College, PA 16803
(814) 237-0567
www.individualandfamilychoices.com
1
Spider Web Walking…
2
Learning Objectives
By the end of this training participants will:
•
Have an increased awareness about the prevalence of Fetal Alcohol Spectrum Disorders in
the domestic and international populations of adopted/fostered children based upon
available research and formalized studies.
•
Have increased knowledge regarding the negative consequences of prenatal alcohol and
drug exposure on the psychological, physical, emotional, cognitive, interpersonal, and
neurological systems of children exposed to substances in utero regardless of birth or
adopted status.
•
Gained important knowledge regarding the direct effects of alcohol on developing brain
structures based on PET/fMRI and SPECT studies and how these effects translate into
cognitive, emotional and behavioral symptoms post birth.
•
Possess detailed information regarding available resources for parents and professionals
working with this population.
•
Have integrated knowledge concerning the misdiagnosis of children with FASDs which
results in mismatched treatment interventions that may actually worsen the outcomes for
these children.
•
Have learned 3-5 strategies or interventions which are helpful to the populations of
adopted/fostered and birth children who also have FASDs.
3
Overview of Presentation
The Morning Session
•
Introductory Remarks
– Definitions and concepts
•
Current Models of FASDs.
– Incidences of FASDs in US and foreign children whether foster/adopted or
birth status
•
Signs and Symptoms
– Visible versus invisible
– Attachment versus FASD versus Complex Trauma
– FASD versus true ADHD versus PTSD versus LDs
•
Some Helpful Strategies, Tools and Resources for Parents
•
Questions and Answers/ Evaluations
4
Overview of Presentation
The Afternoon Session
•
Introductory Remarks: Some guidance from the research
•
Medication issues
•
Empirically Supported Strategies
•
Five empirically validated model programs
•
Common basic ingredients
•
Parental Involvement
•
What we see working in State College, PA
–
–
–
–
–
School collaboration and IEP considerations
EMDR and bilateral stimulation
Neurofeedback
Attachment focused Family Therapy
IFS/Parts work with both parents and their children (Video Clips)
Questions and Answers/ Filling out evaluation forms
5
What is FASD?
“Fetal Alcohol Spectrum Disorder refers to a
constellation of physical and mental birth defects
that may develop in individuals whose birth mothers
consumed alcohol during pregnancy.” (Duquette et
al., 2006)
“Ethanol freely crosses the placenta, thus directly
affecting developing fetal cells and tissues.”
(Niccols, 2007)
Alcohol as are other drugs as well is a teratogen.
6
History
•
First reference to adverse effects of alcohol on the fetus:
– “Beware and drink no wine or strong drink…for lo, you shall conceive and bear a
son.” (Judges 13:4, 5)
•
First scientific study
– Sullivan 1899; increased rate of still-birth and infant death in children of alcoholic
women
•
1940s: Haggard and Jellinek concluded that the developmental abnormalities of children
born to alcoholic mothers were secondary to the environment in which they were raised.
•
1950’s and 1960’s: French studies identified children of alcoholic mothers as having
malformations, growth deficiency, and psychomotor disturbances (Lamache, 1967;
Lemoine, Harousseau, Borteryu, & Menuet, 1968 as cited in Niccols, 2007). No one really
paid too much attention.
•
1970s: interest in the adverse effects of alcohol increased and concern about alcohol as a
teratogen was mentioned. Streissguth, now a famous researcher in the field of FASDs
started researching the patterns of malformation that occurred in children born to alcoholic
mothers who drank while they were pregnant and the term Fetal Alcohol Syndrome was
coined.
•
1980s-the new millennium in 2009 there have been hundreds of investigations identifying
the risks and consequences of consuming alcohol during pregnancy and these reports
have been supplemented by animal experimental study as well. Streissguth (1997) in her
book Fetal Alcohol Syndrome reports on her most comprehensive well know study.
•
Lots of studies have looked at the characteristics of children prenatally exposed and new
brain imaging technologies have really helped to link brain effects to behavioral
expressions or manifestations.
•
Very few studies on how to assist persons who have been exposed.
7
Current Model and Conceptions
of Fetal Alcohol Spectrum
Disorders
• From animal studies (rats)
• Investigations on children, adolescents and
adults with known histories of maternal use
during pregnancy including post-mortem
evaluations
• Research in the last 10 years has been
greatly prolific due to new technologies in
fMRIs, SPECT scans and other neuroimaging procedures.
8
FASDs
38 % of all individuals who have a FASD have the physical
craniofacial features which means that 62% do not!
9
Facial Anomalies
From Wattendorf et al., (2005)
10
Examples of Variability
11
The Faces of Persons who have Fetal
Alcohol Syndrome
12
People who have FASD
13
Diagnosis of Fetal Alcohol Spectrum Disorders
•
Fetal Alcohol Syndrome
(American Academy of Pediatrics, 2000)
–
–
–
–
•
Confirmed maternal alcohol consumption
Growth deficiency
Specific patterns of anomalies
Central nervous system abnormalities
FAS Diagnostic and Prevention Network (2004) supports the 4 digit
Diagnostic code of all FASDs introduced by Astley and Clarren (1997) as
cited in Pei & Rinaldi (2004).
1.
2.
3.
4.
Growth impairment
The FAS facial phenotype
Evidence of brain damage
Prenatal alcohol exposure
This system uses a team approach and investigates all of these four areas
comprehensibly and then the team rates these four items are rated on a
four point Likert scale. A full diagnosis of FAS requires 3s and 4s in all
four categories. Other diagnosis (ARND; FAE, pFAS etc.) have scores
that vary that are greater than 1.
•
Diagnosing in Cutting Edge Ways
–
Eye movement deficits (Green et al., 2009)
–
Functional MRIs, SPECT Scans, PET Scans
14
Prevalence of FASD in the US Population
Statistics on FASD in US
For full blown FAS:
CDC 0.2-1.5/1000 births
Other Studies suggest:
0.5-2.0 per 1000 births*
For all FASD:
Researches believe all FASDs are
4Xs the prevalence of FAS.
10 per 1000 births or 1% of the US
population*
UDHHS (2007): 40,000 newborns a
year meet the criteria for a FASD.
High Risk US Populations:
Native Alaska 3.0-5.6 per 1000 births*
Native American 9-10 per 1000 births
*Source: NIAAA: May & Gossage
retrieved 2008
15
Prevalence of Prenatal Drug
Exposure
• Chasnoff (1989): 11% of all newborns,
approximately 459,690 are exposed
prenatally each year.
• Gomby & Shiono (1991): 739, 000 women use
illicit drugs during pregnancy every year.
• Schipper (1991): A substance exposed infant
is born more frequently than once ever 90
seconds.
16
FASD and Prenatal Drug Exposure Incidences in US
Foster/Adopted Children
Not much is known.
Wedding et al., (2007): psychologist did not have accurate
understanding about FASDs, danger of alcohol use in
pregnancy.
Peadon et al., (2008): Very few places do accurate
diagnosis of FASDs and most are located in North
America.
What is known follows:
Foster Children study in Washington State.
Astley, Stachowiak, Clarren,
& Clausen (2002)
FAS 10-15 times higher than
in the general population
Mayet et al., (1983), Streissguth et al., (1985) estimated
that 73 to 80 % of all children in US foster care or placed
for adoption have full blown FAS.
Ehrmann (2006) found that 28% of adopted children out of
the US foster care system were exposed to alcohol
prenatally and 47% were exposed to some illicit drug
prenatally.
17
Adopted Children from Foreign
Countries
Eastern Europe
15 per 1000 births
Extrapolated to approximately
21,000 children born with FASD each year
Source: Orphan Doctor @
www.orphandoctor.com
Miller it al., 2006
Phenotypic Survey of Children residing in
Russian Orphanages revealed that 45% of the
children had intermediate and 15% had high
phenotypic expression scores suggesting
prenatal exposure To alcohol.
18
Risk Factors
•
Dose of alcohol
•
Pattern of exposure
– Binge versus chronic
•
Developmental timing
Of exposure
•
Genetic variation
•
Maternal characteristics
•
Synergistic reactions with
other drugs
•
Interaction with nutritional
variables
19
Dosage Effect
Dosage Effect on Subsequent Births
FAS with Multiple
Comorbidities
FAS
Severity
1 minor disorder
or defect
Often unaffected
1st Child
2nd Child
3rd Child
4th Child
Source: Larry Burd, PhD
North Dakota Fetal Alcohol Syndrome Center
20
501 N. Columbia Road
Grand Forks, ND 58203
Dosage Example
First
Second
Third
Fourth
Fifth
•No FASD
even though
maternal
consumption
happened
•Lots of
allergies.
•Became a
drug addict
now in
recovery.
•Learning
•Seizure
disorder and
alcohol and
drug
addicted
•Full blown
FAS
disabilities.
•Depression.
21
Developmental Timing of Exposure
22
The Rest of The Story
Streissguth and Colleagues
Primary Disabilities:
• Lower IQ
• Impaired ability in reading, spelling,
and arithmetic
• Lower level of adaptive functioning;
more significantly impaired than IQ
23
Typical Disabilities
• Typical Disabilities:
– Sensory Integration Issues (Franklin, Deitz, Jirikowic & Astley,
(2008)
• Researchers found high correlation between sensory integration and
processing measures and the Achenbach CBCL
– In general Children with FASDs
•
•
•
•
•
Are overly sensitive to sensory input
Upset by bright lights or loud noises
Annoyed by tags in shirts or seams in socks
Bothered by certain textures of food
Have problems sensing where their body is in space (i.e., clumsy)
24
Typical Disabilities Continued
•
Memory Problems
– Working memory
– Multiplication
– Time sequencing
•
Information Processing Problems
–
–
–
–
–
–
–
Do not complete tasks or chores and may appear to be oppositional
Have trouble determining what to do in a given situation
Do not ask questions because they want to fit in
Say they understand when they do not
Have verbal expressive skills that often exceed their level of understanding
Misinterpret others’ words, actions, or body movements
Have trouble following multiple directions
25
Typical Disabilities Continued
•
Executive Function Problems
–
–
–
–
–
–
–
–
–
•
Go with strangers
Repeatedly break the rules
Do not learn from mistakes or natural consequences
Frequently do not respond to point, level, or sticker systems
Have trouble with time and money
Give in to peer pressure
Cannot entertain themselves
Trouble shifting from task to task
Attention issues
Self-Esteem and Personal Issues
–
–
–
–
–
Function unevenly in school, work, and development
Experience multiple losses
Are seen as lazy, uncooperative, and unmotivated
Have hygiene problems
Do not accurately pick up social cues
26
Typical Disabilities Continued
Hearing, speech and language
• Due to craniofacial abnormalities of FAS
– Cleft palate
– Otitis media with effusion and conductive hearing
loss
– Voice dysfunction, articulation disorders
– Speech and language delays
– Language abilities seem lower than would be
expected given child IQ
27
Typical Disabilities Continued
• Social Development Issues
– Atypical attachment behavior and impairment in
state regulation
– Outgoing, socially engaging, affectionate and
excessively friendly
– Preschoolers tend not to appear to differentiate
familiar from unfamiliar
– Studies citing parental and teacher reports
indicate arrested social development rather than
delayed social development
– Deficits in Theory of Mind (TOM)
28
Secondary Disabilities
• Mental health issues
• Disrupted school experience
• Trouble with the law
– They lie (Rasmussen, Talwar, Loomes, & Andrew (2008)
• Inappropriate sexual behavior
• Confinement in jail or treatment facilities
• Alcohol and drug problems
• Dependent living
• Employment problems
29
Percentage of Persons with FAS or
FAE that had Secondary Disabilities
 = Age 6+
 = Age 12+
 = Age 21+
30
FASDs and the Brain
for an excellent summary of the neuroimaging of cognitive function in
FASDS see Malisza (2007)
31
Alcohol Affects the Brain
Source: Teaching Students with Fetal Alcohol Spectrum Disorders
Florida State University Center for Prevention and Early
Intervention Policy (2005)
32
Brain Structure and Function Studies
Damage depends on the state of embryological
development
• Conception to first weeks of prenatal development:
– cytotoxic or mutagenic
• 4-10 weeks after conception
– Excessive cell death in the CNS and abnormal nerve cell
migration
– Disorganization of tissue structure and microcephaly
• 8-10 weeks and on
– Disorganization and or delay in cell migration and development
• Third Trimester
Damage to the cerebellum, hippocampus, and prefrontal cortex
33
Continuum of Brain Dysfunction
Continuum of Brain Dysfunction from Prenatal Alcohol Exposure
Decreased Neuron
Production
Prenatal Ethanol
Exposure
Small Brain
Neurotransmission
Pathway
Abnormal
Activity
Neurotransmitter
Structural
Brain Abnormalities
Electrical
Dysfunction
Modularity
Migration
Abnormalities
Sensory
Impairments
Learning Impairments
Cognitive-Behavioral Dysfunction
Abnormal Apoptosis
(Pruning)
Loss of IQ
CNS
Dysfunction
Developmental Delays
Learning Disabilities
Mental Retardation
Impairments in:
- Memory
- Attention
- Adaptive Behavior
- Use of Social Rules
- Sleep
- Behavior Regulation
Source: Larry Burd, PhD
North Dakota Fetal Alcohol Syndrome Center
501 N. Columbia Road
34
Grand Forks, ND 58203
Before Birth
• Low growth rate due to suppression of
growth hormone in hypothalamus
• Increases HPA activity and disrupts
hormonal interactions between maternal and
fetal systems affecting the development of
fetal metabolic, physiologic and endocrine
functions
• Disrupts synaptogenesis causing neurons to
commit suicide (die by apoptosis) on a
massive scale
35
Disrupted Synapsogenesis
36
Early Development
• HPA disruptions result in high basal and post stress corticol
levels
• Hyper-responsiveness to stress and immune system
vulnerabilities
• High levels of irritability and feeding and sleeping problems
• As preschoolers: “short, skinny children with butterfly like
movements who are hyperactive and/or excessively friendly
and fearless” (Streissguth & Giunta, 1988).
• Developmental delays, language issues and poor motor
coordination are also noted during this period of development
37
Hippocampus in the Human Brain
38
Hippocampus
• Plays a major role in:
– Short term memory
– Spatial navigation
• In a MRI study Rijkonen, Salonen, Partanen,
& Verho (1999) found that children with FAS
have smaller left hippocampus volume then
right and this is associated with memory
deficits.
39
Hypothalamus in the Human Brain
40
Hypothalamus
• The Hypothalamus does the following
– Hormone regulation and metabolic processes
– Linking of nervous system to the endocrine system via the
pituitary gland
– Controls hunger, thirst, body temperature, fatigue, anger,
circadian cycles and sexual drive and is part of
fight/flight/freeze
• Suppression of growth hormone controlled by
Hypothalamus happens in children with FASD.
• Dysregulation
41
Basal Ganglia in the Human
Brain
42
Basal Ganglia
• A group of nuclei/interconnected in healthy individuals’ brains
with the cerebral cortex, thalamus and brain stem.
• Responsible for:
–
–
–
–
Motor control
Cognition
Emotions
Learning
• MRI studies show disproportionate reductions in basal ganglia
volume in children with FAS and FAE especially in the caudate
nucleus which is involved in higher cognitive functions and
connected neuronally to the frontal lobes where executive
functioning resides (Archibald et al., 2001).
• PET studies reveal reduced metabolic activity in the caudate
nucleus in high functioning adolescents and adults with FAS
(Clark et al., 2000).
43
The Corpus Callosum
44
Corpus Callosum
• What does it do?
– Connects the left and right hemispheres of the brain
– Consists of 200- 250 million contralateral axonal projections
– Inter-hemispheric communication
• Abnormalities in individuals with FAS including agenesis and
thinning in the anterior and posterior regions.
• Displacement of the isthmus and splenium related to deficits in
verbal learning.
• Refer to Roebuck-Spencer, Mattson, Marion et al., 2004 on
some current findings related to the corpus callosum and
bimanual coordination
45
Corpus Callosum in the Human Brain
A. Magnetic resonance imaging showing the side view of a 14-year-old
control subject with a normal corpus callosum; B. 12-year-old with FAS and a
thin corpus callosum; C. 14-year-old with FAS and agenesis (absence due to
abnormal development) of the corpus callosum.
Source: Mattson, S.N.; Jernigan, T.L.; and Riley, E.P. 1994. MRI and prenatal alcohol exposure: Images
provide insight into FAS. Alcohol Health & Research World 18(1):49–52.
46
Alcohol Effects of Corpus Callosum
These two images are of the brain of a 9-year-old girl with FAS.
She has agenesis of the corpus callosum, and the large dark area
in the back of her brain above the cerebellum is essentially empty
space.
Source: Mattson, S.N.; Jernigan, T.L.; and Riley, E.P. 1994. MRI and prenatal alcohol exposure:
Images provide insight into FAS. Alcohol Health & Research World 18(1):49–52.
47
Cerebellum in the Human Brain
48
Cerebellum
•
Responsible for:
•
Integration of neural pathways between cerebellum and cerebral motor cortex
–
–
–
–
•
Motor skills
Balance, coordination
Learning in terms of attention and language and music processing
Sensory perception/ proprioceptive feedback
For individuals with FASDs:
–
–
–
Reductions in cerebellar volume specifically in the anterior vermis.
Reductions are linked to dyslexia
Jacobson et al., (2008)
•
Eye blink conditioning is a cerebellular-mediated Pavlovian conditioning paradigm that
involves contingent temporal pairing of conditioned stimulus (tone) with an unconditioned
stimulus (brief air puff to the eye that elicits a reflexive blink). Children with FASD are impaired
in this response indicating that the cerebellum and brain stem areas are highly affected by
alcohol prenatally. This procedure could help in diagnosis and treatment intervention.
49
Frontal Lobes
For a good resource on executive functioning is Rasmussen & Bisanz (2009)
50
Other Anomalies
• EEG readings (Kaneko et al., 1996)
– Atypical in approximately 50% of the children and
adolescents with FASD
– Reductions in the power of the left H alpha
frequencies suggesting less mature brain activity.
– Prolonged latency in P300 spikes in parietal
cortex suggesting deficits in information
processing.
51
Other Anomalies Continued
•
Too much grey matter
•
Not enough white matter
•
Similar metabolic activity in both hemispheres when it is supposed to
be different
•
Too much blood in the right frontal region which is characteristic of
children with executive function problems
•
Fagerlund, Heikkinen, Autti-Ramo et al., 2006
– “First evidence for in vivo brain metabolic alterations in a group of
adolescents and young adults with FASD. Lower NAA/Cho and NAA/Cr in
several anatomical locations from cerebral and cerebellar areas compared
with controls. Alterations were seen in frontal and parietal cortices, frontal
white matter, corpus callosum, thalamus and cerebellar dentate nucleus.
These findings suggest that long standing or permanent biochemical
alterations can occur in response to prenatal exposure to alcohol.” p. 2100
52
Interventions: What will Help?
• Lots of studies on characteristics and
brain differences
• Not a great deal of rigorous study on
effectiveness or efficacy.
53
Premji et al., 2006
Only three intervention studies out of ten had the rigor
needed required to support efficacy.
“Conclusion: There is limited scientific evidence upon
which to draw recommendations regarding
efficacious interventions for children and youth with
a Fetal Alcohol Spectrum Disorder. Clinicians,
researchers, service providers, educators, policy
makers, affected children and youth and their
families and others need to urgently collaborate
to develop a comprehensive research agenda for
this population.”
54
Common Cooccurring/Misdiagnoses of FASD
•
•
•
•
•
•
•
•
•
•
•
•
•
ADD
ADHD
ODD
RAD
LD
Speech and language delay
PDD
Developmental Receptive Language Disorder
Sensory Integration Dysfunction
Conduct Disorder, Seriously Emotionally Disturbed
Borderline Personality Disorder
Antisocial Personality Disorder
Autism, Aspergers
55
Misdiagnosis
• ADHD
– Coles et al., as cited in Lockhart (2001)
• Two groups of adolescents (FASD vs. ADHD)
• FASD group had intact scores in auditory processing but impaired
scores in visual processing adding to the growing evidence that
attention problems of individuals with FASDs may be different than
those who have ADHD without prenatal alcohol exposure.
– Hausknecht et al., (2006)
• Rats exposed prenatally to alcohol have attention deficits similar to
children with FASD & ADHD.
– Mattson et al., (2006)
• Children with FASDs have pervasive deficits in visual focused
attention and deficits in maintaining auditory attention over time but no
deficits in the ability to disengage and reengage attention when
required to shift attention between visual and auditory stimuli although
reaction times to shift were slower.
56
Misdiagnosis
• FASD versus ODD
• FASD Versus RAD
• FASD Versus Autism Spectrum Disorder
57
Protective Factors
• Stable home
• Early diagnosis
• No violence against oneself
• More than 2.8 years in each living
situation
• Recognized disabilities
• Diagnosis of FAS
• Good quality home from
ages 8 to 12
• Basic needs met for at least
3/4th of the person’s life
58
Helpful Strategies for Parents
•Education that helps parents
distinguish between I won’t
and I can’t in their children.
Parents have to “think
younger”
•SELF Led Parenting: helping
parents to discover their
own triggers and then
resolving them.
•Respite in either direction
•Support groups.
59
Helping a Child with FASD
• Graefe (2003):
– The 4 S’s + C
Structure, Supervision, Simplicity, Steps
+
Context
60
Strategies for Children with FASD
Working Memory Issues
Yellow Stickies.
What did Ben do well today? Take a
picture of the sand tray.
Bilateral Stimulation to keep
something in memory.
IEP at school to accommodate this
as a brain based issue due to
permanent impairment from fetal
alcohol exposure.
External memory reminders
61
Example: External Memory Reminders
Step
Activity
1
Rise and shine when Daddy V. wakes
you up with a hug!!
2
Go to the bathroom, wash your face and
hands and brush your teeth ….thank you very
much!!!
3
Put on your clothes, socks, and sneakers left
out the night before…
4
Make your bed
5
Put PJs in the hamper
6
Get back pack and come to kitchen for good
eats made by Mommy J. who loves you soooo
much!!
7
Picture
Cue
Check off
when done
Hand over this checklist for points!!!
62
Chore Check List Example
Step
1.
Take Endust, spray it on a rag and wipe off all tables, shelves,
items on tables and shelves and picture frames.
2.
Put the old newspapers in a plastic bag and place in the
recyclable container.
3.
Take paper towels and Windex and clean all the windows.
4.
Use the sweeper to vacuum the entire rug.
5.
Use the broom and the dust pan to sweep all the dust, dirt and
and dog hair off the steps.
6.
Put all cleaning supplies, brooms and vacuum away.
7.
Recheck to make sure that you have done everything on this
list in the best way possible.
8.
Once all the items are checked in hand this in for points!!
63
Strategies for Helping Children with
FASD
Problems with Cause and Effect
Let natural consequences happen
as long as they are not
dangerous or deadly.
Writing for Greater Self
Knowledge Exercise Sheets
Choices Have Consequences
EMDR protocol
64
More Strategies
• Behavioral offenses
– ALWAYS have the child make amends in a concrete physical way.
– Teach for habituation rather then understanding
• Time management
– Describe time in TV episodes
• Affect Regulation
–
–
–
–
–
–
Resource development with bilateral stimulation
Deep breathing and body signal awareness
Mindfulness techniques
Drumming
Self calming or self soothing strategies
Find a nook or cranny for the child to “tuck in”.
• For motor coordination and self-esteem
– Feather exercise
65
Resources
• SAMHSA FASD Center for Excellence: fasdcenter.samhsa.gov
• Centers for Disease Control and Prevention FAS Prevention Team:
www.cdc.gov/ncbddd/fas
• National Institute on Alcohol Abuse and Alcoholism (NIAAA):
www.niaaa.nih.gov/
• National Organization on Fetal Alcohol Syndrome (NOFAS):
www.nofas.org
• National Clearinghouse for Alcohol and Drug Information:
ncadi.samhsa.gov
• Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit
Diagnostic Code: Third Edition (2004)
• http://depts.washington.edu/fasdpn
• These sites link to many other Web sites.
66
The Afternoon Session
Slides from this one forward are for the
afternoon presentation.
67
Professional Therapeutic Interventions
Introductory Comments
Lockhart (2001)
• Identification is a core issue as individuals with FASDs look like they have
many other types of disorders & medication as well as psychotherapy
interventions may not be successful with them.
•
Teasing out what is an organically based disability and not willful disobedience
or other motivation from behavior that is willful is essential.
•
Multilevel approach that includes: psychopharmacological treatment, behavior
therapy, proper educational placement, speech and language services,
occupational therapy, direct advocacy (with a personal 1 to 1 aide), parent
education and support, social services, and vocational services
Green et al. (2009)
• Canadian study using the Cambridge Neuropsychological test Automated
Battery were able to adequately distinguish children with FASDs regardless of
craniofacial dysmorphology and measures of children with FAS with
dysmorphology did not differ from children with FASDs without the
dysmorphology.
68
Professional Therapeutic Interventions
Continued
Medication Issues
•
Frankel, Paley, Marquardt & O’Connor (2006)
– Type of medication affected outcome in Child Friendship Training for
children with FASDs.
– Children with FASDs on prescribed neuroleptic medications (risperdone,
olanzapine) showed better outcomes from CFT then children with FASDs
on stimulant medication (amphetamine salts, methylphenidate,
dextroamphentamine).
•
Doig, McLennan & Gibbard (2008)
– Evaluated the change in core ADHD symptom clusters following treatment
with ADHD medications in a group of children with FASD.
– Children with dual FASD-ADHD diagnosis may display more difficulties
with inattention than other ADHD related symptoms.
– ADHD medication may be less able to normalize the inattention symptom
cluster in children with FASD-ADHD.
– Are the ADHD symptoms manifested in this group of children a function of
alcohol exposure versus other factors that lead to ADHD?
69
Professional Therapeutic Interventions
Continued
Empirically Supported Strategies
•
Roebuck-Spencer & Mattson (2004)
– CVLT-C Versus VL-WRMAL
– CVLT-C=Implicit Learning Strategy
– The strategy is “Semantic Clustering”
– When children with a FASD had IQ> 80 and they used Semantic Clustering,
their retention scores were the same as children in the healthy control
group.
– The researchers suggest that for children who have FASDs “that to ensure
optimal learning, it is important to provide opportunities for semantic
clustering (or other relevant leaning strategies) and provide enough trials
so that children have an opportunity to rehearse newly learned information
after having reached their learning plateau.” p 1430
70
Professional Therapeutic Interventions
Continued
Kalberg & Buckley (2007)
• Good information on structuring the
environment in the school, home and
community settings
• Cognitive Control Therapy
71
Professional Therapeutic Interventions
Continued
Bertrand (2009)
•
Centers for Disease Control and Prevention (CDC) provided federal
grant money.
•
Findings of five innovative research projects exploring interventions
for children with FASDs
•
Objectives of each intervention was to improve the developmental
outcomes of individuals with FASD, reduce secondary conditions and
improve the lives of families affected by FASDs.
•
Grantees had to incorporate three common components in the
intervention trials: 1. had to target a specific area of deficit or risk
among the targeted population; 2. provide children in both treatment
and control groups with multidisciplinary assessments that guided
referrals for standard care; 3. incorporate specific instruction and
training for parents and caregivers regarding basic information about
FASDs, advocacy skills and caregiver support.
72
Professional Therapeutic Interventions
Continued
Bertrand, 2009 continued
Study 1: Project Bruin Buddies: A social skills training program to improve peer
friendships for children with FASDs (University of California at Los Angeles)
–
Examined the effect of parent-assisted Children’s Friendship Training (CFT)
–
Parents were facilitators of the children’s social skills performance. They also took
part in educational, support and training groups.
–
Program was adapted for the neurocognitive deficits common to children with FASDs
–
Skills taught were: 1. social network formation with the aide of the parent;
2. informational interchange with peers leading to common-ground activity; 3. entry
into a group of children already in play; 4. in-home play dates; 5. conflict avoidance
and negotiation.
–
Skills were taught didactically through instruction on simple rules of social behavior;
modeling, rehearsal and performance feedback during treatment sessions; rehearsal
at home; homework assignments; and coaching by parents during play between
children.
–
Social skills of the children were significantly increased, behavioral problems were
significantly decreased and the positive outcomes continued to be robust at the three
month post test measure. Parent knowledge regarding FASDs and parent satisfaction
with their children and the program increased.
73
Child Friendship Training
O’Connor, Frankel, Paley et al., (2006)
Description of Child and Parent Treatment Sessions
Session
Child Group Topic
Parent Group Topic
1
Rules of the group; elements of good
communication
Goals and methods of treatment; limitations of
intervention: what not to expect
2
Having a conversation
Having a conversation
3
Joining a group of children already at play:
“slipping in”
Supporting child friendships
4
Joining a group of children already at play:
“slipping in”
Joining a group of children already at play:
“slipping in”
5
How to be a good sport
Joining a group of children already at play:
“slipping in”
6
How to be a good sport
Appropriate games for play dates
7
Rules of being a good host
Play dates
8
How to handle teasing
How to handle teasing
9
Unjustified accusations
How to handle adult complaints about child’s
behavior
10
How to be a good winner
How to be a good winner
11
Bullies and conflict situations
Bullies and conflict situations
12
Graduation
Graduation
74
Child Friendship Training
Schonfeld, Paley, Frankel and O’Connor (2009)
• Behavioral regulation predicted the
effectiveness of CFT for children with FASDs
regardless of general intellectual functioning.
• The ability to control impulses, solve
problems flexibly and monitor emotional
responses significantly predicted
improvement in social skills and reduction in
problem behaviors following CFT.
75
Professional Therapeutic Interventions
Continued
Bertrand, 2009 continued
Study 2: Georgia-Sociocognitive habilitation using math interactive
learning experience (MILE) program (Marcus Institute)
– Focused on mathematical functioning
– Developed and adapted learning strategies to compensate for core alcohol
related neurodevelopmental deficits to facilitate the math learning
– Included intensive short term individual instruction of each child as well as
for the child’s teacher and caregiver. Teachers and caregivers were also
educated about FASDs.
– Found to have positive long term consequences on academic achievement
and educational attainment among high-risk children and to be beneficial
in cognitive rehabilitation programs for children with acquired brain
damage. Authors credited the improved global measure of behavior in the
children to the training and support groups they conducted with the
caregivers
76
Professional Therapeutic Interventions
Continued
Bertrand, 2009 continued
Study 3: Neurocongnitive habilitation for children with FASDs (Children’s Research Triangle)
–
Specifically aimed at developing and evaluating a program of neurocognitive habilitation for
children who had been in foster care or who had been adopted and who had a diagnosis of an
FASD.
–
The researchers noted that the very factors that Streissguth et al., and others have identified as
protective of children with FASDs in developing secondary disabilities are the one that children in
the child welfare system lack such as being raised in a stable and nurturing home, a diagnosis prior
to age 6, having no sexual or physical abuse history, not changing households ever few years, not
living in a poor quality home, receiving early intervention.
–
Provided education and support to enhance the families’ capabilities to care for their children and
focused on improvement of the child’s executive functioning. They taught the children selfregulation skills, EF skills, memory skills, cause and effect reasoning, sequencing, planning and
problem solving.
–
They used the Alert Program (Williams & Shellenberger, 1996). (The brain is like a car engine and
can make the body run in high, low or the just right gear…etc.)
–
Children learned speed identification skills, strategies to change gear and speed, sensory motor
monitoring skills and regulation of state of arousal.
–
Results of numerous measures indicated that children in the treatment group improved significantly
in executive functioning skills and overall regulation ability and also exhibited an increased ability
to tell more robust and healthy stories in a projective storytelling test. Researchers reasoned that
this was due to the emphasis in the program of teaching children cause and effect thinking and
sequencing.
77
Professional Therapeutic Interventions
Continued
Bertrand, 2009 Continued
Study 4: Parent-Child Interaction Therapy: Application of an
evidence-based treatment to reduce behavior problems among
children with FASDs (University of Oklahoma Health Sciences
Center)
– Aim of the study was to evaluate two group based interventions for
children with FASDs that would reduce behavior problems and
decrease parental stress.
– Parent-Child Interaction Therapy (PCIT) versus Parent Only
Parenting Support & Management (PSM).
– Both PCIT and PSM resulted in positive improvements in the
families in the study but more parents were satisfied with the PCIT
treatment than PSM.
78
Professional Therapeutic Interventions
Continued
Bertrand, 2009 Continued
Study 5: Families Moving Forward (FMF): A behavioral consultation intervention to
improve outcomes for families raising children with FASDs (University of
Washington)
–
The goal was to evaluate an intervention designed to improve caregiver self efficacy,
meet family needs and reduce child problem behaviors.
–
Compared the FMF program to community standard care
–
Focuses on parenting attitudes and parenting responses toward their child’s problem
behaviors.
–
Central focus is the teaching of caregivers the skills of “parent-friendly” positive
behavior support approaches.
–
Teaches parents antecedent-based behavior strategies, advocacy skills and ways to
develop “accommodations” for the child in the home and school environments.
–
Helps parents change their attitudes and cognitions most centrally about their
understanding of the child’s behavior (it’s about brain damage not willful disobedience
etc.”
–
Ongoing data collection and evaluation indicate that FMF is a low cost feasible
intervention that assists parents of children with FASDs in developing more positive
parenting strategies as well as more positive attitudes toward their children which
then leads to better behavioral and emotional outcomes for the children.
79
The Common Basic Ingredients
1. Parent education, training and support
2. Explicit instruction of the children.
3. Individualized and targeted interventions can be
implemented within current community
services.
80
Parental Involvement
• Paley et al., 2006
– Study on the effects of raising a child with FASDs
on the parent
– Parents get stressed out because:
• Problems of the child
• Ineffective interventions
• Anxiety about the well being and eventual independence
of the child
• Adoptive parents felt more stressed than biological
parents
• Parents also feel more stressed when they
have not had resolution in their own trauma
experiences
81
What we see working in State College
• Neurofeedback
• EMDR
• Parts Work/ IFS for the children and the
parents
– Clips of parts work with B.
82
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