Attachment Disordered Children with Fetal Alcohol and Drug ...

Attachment Disordered Children with Fetal Alcohol and Drug ...

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 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 drinkfor 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. 1950s and 1960s: 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 @ 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):4952. 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):4952. 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 Co-occurring/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 persons life 58 Helpful Strategies for Parents Education that helps parents

distinguish between I wont and I cant 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 Ss + 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 Hand over this checklist for points!!! Picture Cue Check off when done 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:

Centers for Disease Control and Prevention FAS Prevention Team: National Institute on Alcohol Abuse and Alcoholism (NIAAA): National Organization on Fetal Alcohol Syndrome (NOFAS): National Clearinghouse for Alcohol and Drug Information: Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit

Diagnostic Code: Third Edition (2004) 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 & OConnor (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 Childrens Friendship Training (CFT) Parents were facilitators of the childrens 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 OConnor, 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 childs 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 OConnor (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 childs 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 (Childrens 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 childs 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 gearetc.) 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 childs 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 childs behavior (its 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 References American Academy of Pediatrics. (2000). Fetal alcohol syndrome and alcohol related neurodevelopmental disorders. Pediatrics, 106(2), 358-361. Astley, S., Stachowiak, J., Clarren, S., & Clausen, C. (2002). Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population. Journal of Pediatrics, 141(5), 712-717.

Barr, H., Streissguth, A., Darby, B., & Sampson, P. (1990). Prenatal exposure to alcohol, caffeine, tobacco and aspirin: Effects on fine and gross motor performance in 4-year old children. Developmental Psychology, 26(3), 339-348. Bennett, D., Bendersky, M., & Lewis, M. (2008). Childrens cognitive ability from 4 to 9 years old as a function of prenatal cocaine exposure, environmental risk, and maternal verbal intelligence. Developmental Psychology, 44(4), 919-928. Bertrand, J. (2009). Interventions for children with fetal alcohol spectrum disorders (FASDs): Overview of findings for five innovative research projects. Research in Developmental Disabilities, 30, 986-1006. Bishop, S., Gahagan, S., Lord, C. (2007). Re-examining the core features of autism: a comparison of autism spectrum disorder and fetal alcohol spectrum disorder. Journal of Child Psychology and Psychiatry, 48(11), 1111-1121. Chasnoff, I. (1989). Drug use in women: Establishing a standard of care. Annals of the New York Academy of Science, 562, 208-210. 83 References Continued Dean, R., & Davis, A. (2007). Relative risk of perinatal complications in common childhood disorders. School Psychology Quarterly, 22(1), 13-25. Doig, J., McLennan, J., Gibbard, W.B. (2008). Medication effects on symptoms of attention/deficit/hyperactivity disorder in children with fetal alcohol spectrum disorder. Journal of Child and Adolescent

Psychopharmacology, 18(4), 356-371. Duquette, C., Stodel, E., Fullarton, S., & Hagglund, K. (2006). Persistance in high school: Experiences of adolescents and young adults with fetal alcohol spectrum disorder. Journal of Intellectual and Developmental Disability, 31(4), 219-231. Fagerlund, A., Heikkinen, S., Autti-Ramo, I., Korkman, M., Timonen, M., Kuuse, T., Riley, E., & Lundborn, N. (2006). Brain metabolic alterations in adolescents and young adults with fetal alcohol spectrum disorders. Alcoholism: Clinical and Experimental Research, 30(12), 2097-2104. FAS Diagnostic and Prevention Network. (2004). Diagnostic guide for fetal alcohol spectrum disorders: The 4digit diagnostic code (third edition). Washington: University of Washington. Frankel, F., Paley, B., Marquardt, R., & OConnor, M. (2006). Stimulants, neuroleptics, and childrens friendship training for children with fetal alcohol spectrum disorders. Journal of Child and Adolescent Psychopharmacology, 16(6), 777-789. Franklin, L., Deitz, J., Jirikowic, T., Astley, S. (2008). Children with fetal alcohol spectrum disorders: Problem behaviors and sensory processing. The American Journal of Occupational Therapy, 62(3), 265-273. Gomby, D. & Shiono, P. (1991). Estimating the number of substance exposed infants. The Future of Children: Adoption, 1(1), 17. Green, C.R., Mihic, A.M., Brien, D.C., Armstrong, I.T., Nikkel, S.M., Stade, B.C. Rasmussen, C. (2009). Oculomotor control in children with fetal alcohol spectrum disorders assessed using a mobile eyetracking laboratory. European Journal of Neuroscience, 29, 1302-1309. 84 References Continued Green, C.R., Mihic, A.M., Nikkel, S.M., Stade, B.C., Rasmussen, C., Munoz, D.P., Reynolds, J.N. (2009). Executive

function deficits in children with fetal alcohol spectrum disorders using the Cambridge Neuropsychological Tests Automated Battery (CANTAB). The Journal of Child Psychology and Psychiatry, 50(6), 688-697. Hausknecht, K., Acheson, A., Farrar, A., Kieres, A., Shen, R., Richards, J., & Sabol, K. (2005). Prenatal alcohol exposure causes attention deficits in male rats. Behavioral Neuroscience, 119(1), 302-310. Jacobson, S., Stanton, M., Molteno, C., Burden, M. et al., (2008). Impaired eyeblink conditioning in children with fetal alcohol syndrome. Alcoholism: Clinical and Experimental Research, 32(2), 365-372. Kable, J., Coles, C., & Taddeo, E. (2007). Socio-cognitive habilitation using the math interactive learning experience program for alcohol affected children. Alcoholism: Clinical and Experimental Research, 31(8), 1425-1434. Kalberg, W., & Buckley, D. (2007). FASD: what types of intervention and rehabilitation are useful? Neuroscience and Biobehavioral Reviews, 31, 278-285. Lawrence, R., Bonner, H., Newsom, R., & Kelly, S. (2008). Effects of alcohol exposure during development on play behavior and c-Fos expression in response to play behavior. Behavioral Brain Research, 188, 209-218. Lockhart, P. (2001). Fetal alcohol spectrum disorders for mental health professionals- A brief review. Current Opinion in Psychiatry, 14, 463-469. Malisza, K. (2007). Neuroimaging cognitive function in fetal alcohol spectrum disorders. International Journal of Disabilities in Human Development, 6(2), 171-188. Mattson, S., Calarco, K., & Lang, A. (2006). Focused and shifting attention in children with heavy prenatal alcohol exposure. Neuropsychology, 20(3), 361-369. Miller, .C., Chan, W., Litvinova, A., et al. (2006). Fetal Alcohol Spectrum Disorders in Children Residing in Russian Orphanages: A Phenotypic Survey. Alcoholism: Clinical and Experimental Research, 30(3), 531-538.

85 References Continued Niccols, A. (2007). Fetal alcohol syndrome and the developing socio-emotional brain. Brain and Cognition, 65, 135-142. OConnor, M., Frankel, F., Paley, B., Schonfeld, A., Carpenter, E., Laugeson, E., & Marquardt, R. (2006). A controlled social skills training for children with fetal alcohol spectrum disorders. Journal of Consulting and Clinical Psychology, 74(4), 639-648. Paley, B., OConnor, M., Frankel, F., Marquardt, R. (2006). Predictors of stress in parents of children with alcohol spectrum disorders. Developmental and Behavioral Pediatrics, 27(5), 396- 404. Peadon, E., Fremantle, E., Bower, C., & Elliott, E. (2008). International survey of diagnostic services for children with fetal alcohol spectrum disorders. BMC Pediatrics, 8(12), 1-8. Premji, S., Benzies, K., Serrett, K., Hayden, K.A. (2006). Research-based interventions for children and youth with a fetal alcohol spectrum disorder: Revealing the gap. Child: Care, Health and Development, 33(4), 389-397. Pei, J., & Rinaldi, C. (2004). A review of the evolution of diagnostic practices for fetal alcohol spectrum disorders. Developmental Disabilities Bulletin, 32(2), 125-139. Rasmussen, C., & Bisanz, J. (2009). Executive functioning in children with Fetal Alcohol Spectrum: Profiles and age-related differences. Child Neuropsychology, 15, 201-215. Rasmussen, C., Talwar, V., Loomes, C., & Andrew, G. (2008). Brief report: Lie-telling in children with fetal alcohol spectrum disorder. Journal of Pediatric Psychology, 33(2), 220-226.

86 References Continued Roebuck-Spencer, T. & Mattson, S. (2004). Implicit strategy affects learning in children with heavy prenatal alcohol exposure. Alcoholism: Clinical and Experimental Research, 28(9), 1424-1431. Roebuck- Spencer, T., Mattson, S., Marion, S. et al. (2004). Bimanual coordination in alcohol-exposed children: the role of the corpus callosum. Journal of the International Neuropschological Society, 10, 536-548. Santostefano, S. (1984). Cognitive control therapy with children: Rationale and technique. Psychotherapy, 21(1), 76-91. Schipper, W. (1991). Testimony before the U.S. House of Representatives Select Committee on Narcotics Abuse and Control. Retrieved from http://www.statistics Schonfeld, A., Paley, B., Frankel, F., OConnor, M. (2009). Behavioral regulation as a predictor of response to childrens friendship training in children with fetal alcohol spectrum disorders. The Clinical Neuropsychologist, 23, 428-445. Seigal, D. (1999). The developing mind. NY: Guildford Press. Siegal, D. (2007). The mindful brain: Reflection and attunement in the cultivation of well-being. NY: W.W. Norton & Co. Streissguth, A., & Kanter, K. (1997). The challenge of fetal alcohol syndrome: Overcoming secondary disabilities. Washington: University of Washington Press. Wattendorf, D., Maj, U., Muenke, M. (2005). Fetal alcohol spectrum disorders. American Family Physician, 72(2), 279-285. Wedding, D., Kohout, J., Mengel, M., Ohlemiller, M., Ulione, M., Cook, K.., Rudeen, K., & Braddock, S. (2007).

Psychologists knowledge and attitudes about fetal alcohol syndrome, fetal alcohol spectrum disorders, and alcohol use during pregnancy. Professional Psychology: Research and Practice, 38(2), 208-211. 87

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