Behavioral Problems in Children with Fetal Alcohol Spectrum Disorder: Lying and Parental Ratings of Executive Functions

1. Behavioral Problems in Children with Fetal Alcohol Spectrum Disorder: Lying and Parental Ratings of Executive Functions Carmen Rasmussen, PhD Department of Pediatrics University of Alberta

2. Neurobehavioral Deficits in FASD • FASD is a term used to refer to an individual who have physical, mental, behavioral, and/or learning disabilities as a result of maternal alcohol consumption. • Executive functioning (EF) is one of the core deficits in children with FASD. • These EF deficits in FASD have been documented on tests of cognitive flexibility, inhibition, planning and strategy use, concept formation and verbal reasoning, set shifting, working memory measures, and fluency – all cognitive-based or ‘cool’ EF tests. • However, very few researchers have examined emotion-related or ‘hot’ EF in FASD and even less have looked at ‘real-world’ EF behaviors in FASD.

3. The Behavioral Ratings Inventory of Executive Functioning (BRIEF) • The BRIEF is a parental and teacher rating scale of a child’s executive functioning behaviors in everyday situations and settings. • Appears to uniquely evaluate a set of metacognitive, behavioral, and emotional abilities that go beyond common psychopathology and behavioral disturbances measured by other behavior rating scales. • Useful in identifying differences in other disorders (ADHD, autism, and traumatic brain injury) and thus shows great promise in highlighting differences between different neurodevelopmental profiles.

4. The BRIEF • Consists of eight clinical scales: • Behavioral Regulation Index (BRI) • Inhibit • Shift • Emotional Control • Metacognition Index (MI) • Initiate • Working Memory • Plan/Organize • Organization of Materials • Monitor • The BRI and MI combine to form the Global Executive Composite (GEC).

5. Goals of the study: • To determine whether children with FASD show deficits on the BRIEF, and more importantly, whether they show a distinctive pattern of strengths and weaknesses on scales of the BRIEF. • Important for developing instruction and remediation that can target specific areas of weakness or build upon areas of strength. • To examine whether gender and age are related to performance on the BRIEF. • Important for understanding the developmental trajectory and gender effects related to EF deficits in FASD, which has strong implications for diagnosis and remediation.

6. Method • Parents/guardians completed the BRIEF on 64 children (37 males, 27 females) with FASD. • All children had a medical diagnosis of an FASD. • The mean age of participants was 8 years, 10 months with a range of 5-16 years.

7. Results • On all scales, mean T scores were significantly higher (meaning more deficit) than the mean of 50 (using 99% confidence intervals). • All mean T scores were in the clinically significant range (65 or above). • Children with FASD displayed deficits on all scales of the BRIEF, with most difficulty on the Inhibit, Working Memory, and Initiate scales and the best performance on Organization of Materials and Plan/Organize.

8. Performance on the BRIEF

9. Results continued… • Gender effects: Females scored significantly higher (relative to other females) than males (relative to other males) on the Inhibit scale as well as on the BRI. • Age differences: On average, older children tended to have higher scores (relative to the norm) than younger children, but this difference was only significant on the Initiate and Working Memory scales.

10. Performance on the BRIEF as a Function of Age Group To examine age effects, children were divided into a younger (5-8 years, n=38) and older (9-16 years, n=26) age group.

11. Conclusions • Children with FASD demonstrated profound EF deficits on the BRIEF. • A distinct pattern of strengths and weaknesses emerged, with scores being poorest on the Inhibit, Working Memory, and Initiate and best on Organization of Materials and Plan/Organize. • Females tended to have significant difficulties on Inhibition which has implications for tailoring intervention for females.

12. Conclusions continued… • The finding that older children showed more difficulty (relative to the norm) than younger children suggests that perhaps adolescence places extra demand on EF behaviors, particularly Working Memory and Initiation, resulting in more pronounced deficits in these areas. • However, further longitudinal research is needed to substantiate this finding. • The BRIEF appears to be a very important tool for documenting ‘real-life’ EF behaviors in children and provides useful clinical data on the complexity of difficulties faced by children with FASD that may not be obtained from traditional cognitive scales.

13. Study #2: Lying in FASD • Secondary disabilities: mental health problems, trouble with the law, confinement, inappropriate sexual behavior, alcohol and drug abuse, dropping out of school. • Behavioral problems and poor social skills. • Impulsive and lack guilt, aggression, delinquency, and low moral maturity. • In a large study of adolescents and adults with FASD it was found that 60% of the sample had been in trouble with the law and 50% had been confined. • A Canadian study found that 23% of youth remanded for a psychiatric inpatient assessment had FASD. (Streissguth et al., 1996; Janzen, et al., 1995; Mattson & Riley, 2000; Roebuck et al., 1999; Sood et al., 2001; Schonfeld et al., 2005; Fast et al., 1999).

14. Study #2: Lying in FASD • Children start telling lies as young as 2 years of age. • Most studies of children’s lying use a temptation resistance paradigm, where children are given the opportunity to lie. • The child is placed in room with a toy and told not to peek at the toy while the experimenter is absent (80-90% of children do peek). They then have a naturalistic opportunity to spontaneously lie when the experimenter returns and asks whether or not the children peeked. • The majority of children between 4 and 7 years of age lie about peeking at a toy, while only 1/3 of 3-year-olds lie. • Some children as young as 3 years of age, and most children by 4 years of age, can and will tell lies. (Newton, et al., 2000; Talwar & Lee, 2002)

15. Study #2: Lying in FASD • The behavioral disturbances, poor social and moral development, along with executive functioning deficits may make children with FASD more likely to lie. • Difficulty with inhibition combined with not understanding the consequences of their actions (cause and effect reasoning) could lead to delinquent behaviors such as lying. • Although lying has frequently been noted as a concern among caregivers of children with FASD there has been no research specifically examining lying in children with FASD.

16. Our Study • The goal of this study was to examine lying among young children (aged 4 to 8 years) with FASD. • Participants: 47 children aged 4-8 years: • FASD group: 23 children (11 girls and 12 boys) with a diagnosis of an FASD. 13 preschool and 10 early elementary children. • Control group: 24 children (11 girls and 13 boys) without FASD. 12 preschool and 12 early elementary children.

17. E: What do you think it is? C: Elmo! C E • E: Oops, I forgot something in the other room, so I have to go get it. I am going to play the last toy for you and you have to guess what it is. But don’t peek at the toy. • Did you turn around and peek at the toy? • What do you think the toy is? • How do you know what the toy is? C E

18. Results Peeking • A similar proportion of children in the FASD group (78%) and Non-FASD group (75%) peeked. • No age or gender differences. Lying: “Did you peek to look at the toy?” • For the FASD group, of the 18 children who peeked, 17 (94.4%) children lied, while only 1 child confessed. • In the Non-FASD group, of the 18 children who peeked, 13 (72.2%) children lied about peeking.

20. Results “Who do you think it is?” • Assesses the child’s ability to maintain semantic leakage control. • Children responded by either saying the correct answer (Mickey Mouse) and thereby implicating themselves in peeking and lying, or they concealed their lie by feigning ignorance or guessing another toy. • 58.8% of the children in the FASD group concealed by either feigning ignorance or guessing another toy, as compared to 38.5% in the Non-FASD group. • For the FASD group only, older children were more likely to conceal their lie than younger children.

21. Conclusions • Children with FASD were more likely to lie than Non-FASD children. • Unlike Non-FASD children, age was not related to lying ability among the FASD group, in that high rates of lying were observed at all ages. • Children with FASD were surprisingly good at maintaining their lies indicating they may be more skilled lie-tellers at an earlier age.

22. Implications • Previous research indicates children who engage in more delinquent behavior are more likely to lie to conceal their behavior and learn to lie successfully. • In this study, children with FASD had a higher rate of lying and were better at concealing their lies, suggesting that FASD children may learn to use lying as a strategy to conceal their transgressions at a young age. • These lying behaviors may be related to later secondary disabilities common in FASD such as trouble with the law and delinquency. (Achenbach & Edelbrock, 1981; Stouthamer-Loeber, 1986; Gervais et al., 2000).

23. Implications • Because this was a game-like experiment, the results do not necessarily mean that children with FASD will lie more often in everyday situations. • Further research is needed to determine whether children with FASD lie more often in other contexts and also whether lying is correlated with later secondary disabilities and frequency of transgressive behaviors. • Research is needed to determine factors that may be related to lying such as executive function deficits. • Special emphasis on helping children with FASD understand the consequences of lying as well as cause-and-effect reasoning may be beneficial.

24. Collaborators • Rosalyn McAuley, University of Alberta • Gail Andrew, Glenrose Rehabilitation Hospital • Carly Loomes, University of Alberta • Shazeen Manji, University of Alberta • Victoria Talwar, McGill University • Katy Wyper, University of Alberta • Special thanks to all those children and families who have participated in our research!

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