Fetal Alcohol Syndrome: Socio-Cognitive Habilitation

1. Fetal Alcohol Syndrome:Socio-Cognitive Habilitation Claire D. Coles, PhD Julie A. Kable, PhD Douglas Lee, MD

2. The Marcus Intervention Project is one of five intervention sites focusing on FASD Centers for Disease Control and Prevention (CDC) UOKLA UWA Chicago UCLA

3. Fetal Alcohol Syndrome: Socio-Cognitive Habilitation Major Goals of the Atlanta Study • Support, educate and empower caregivers • Achieve learning readiness • Case management • Psychiatric assessment • Neurodevelopmental assessment • Behavioral regulation training • Improve mathematical achievement by compensating for core deficits.

4. Why these goals?Caregivers • Caregivers are the principle agents of change. • Parents and caregivers of alcohol-affected children experience stress in their role. • Limited access to resources and support make parenting roles difficult.

5. Why these goals?Learning Readiness • Children have problematic environmental histories • Children may have arousal regulation problems • Unless children are “ready to learn”, methods will not be effective • Significant social/emotional, medical and/or environmental problems must be treated first

6. Why these goals?Math Skills? • Not really just math skills • Math is a marker of underlying “core deficits” that interfere with learning in this area. • Core deficits impact motor skills, arousal regulation, visual/spatial skills and learning. • Teaching methods can address these problems

7. Target Population • Diagnosis of FAS/pFAS • Between the ages of 3 and 9 years • In a consistent placement for the last 6-months and projected stability over the next 6-months • Exclusion criteria: Moderate Intellectual Disability, Other major psychiatric diagnosis that would interfere with learning, Parent characteristics that would interfere with learning

8. Recruitment Sources • Existing client base • New clients requesting Clinical services • Community sample • DFACS (Dept Family and Children’s Services) • Local pediatricians, neurologists, and developmental pediatricians • Community publications (local magazines and newspaper)

9. Intervention Study Design 01=Pre-testing A=Caregiver advocacy training B=Learning readiness C=Math intervention O2=8-wk Post-testing O3=6-mo Post-testing

10. Learning Readiness • Parent Education about FAS • Case/Social Service Management • Psychiatric Evaluation/Medication Management • Neurodevelopmental Evaluation • Educational Management • Behavioral Regulation Training

11. Case Management Services • Assistance with transportation • Assistance with finding appropriate therapeutic services for the child • Assistance with obtaining appropriate parental support services

12. Psychiatric Evaluation • Evaluation and assessment to determine appropriateness and efficacy of any medications • Determine the need for any behavioral/emotional therapy

13. Prevention of Barriers • Transportation if needed • Flexible work hours • Free babysitting • Reimbursement for gas

14. Special Education Services • Neurodevelopmental evaluation • Individualized feedback with a psychologist and special educator • Consultation with special educator regarding advocacy and placement within the school • Special educator may attend the IEP meeting

15. Group Administered Parent Education • Understanding FASD • Caregiver Advocacy Training • Behavioral Regulation Training

16. Caregiver Advocacy Training • Education regarding Fetal Alcohol Syndrome and pFAS. • Learn how to communicate with pertinent professionals regarding their child’s needs and to assist in goal planning for their child. • Learn about the child’s rights within the educational system. • Encouraged to advocate for the children in the context of educational, political, social and legal systems.

17. Behavioral Regulation Training • Learn what behavioral regulation is • Learn what social learning principles are and how to apply them in everyday life • Learn strategies to modify the child’s level of arousal • Learn strategies to modify the child’s environment to prevent problematic situations • Learn how to get improve compliance

18. Math Intervention • Given to half the sample. Group assignment is determined by randomly drawing names after completing the second group session • Strategies • Active learning model (plan-do-review) • High Scope • Visual materials and aids to teach math • Individualized based on cognitive and math development

19. Core Deficits Impact on Mathematical Thinking Global Deficits “IQ” Visual-spatial Math Working memory Prenatal Alcohol Visual-motor

20. Group activation maps of EtOH and control subjects (transverse sections). a) EtOH subject group map (z=13) showing activation in the right and left temporal lobes (green arrows), posterior cingulate (dark blue arrow), angular gyrus (purple arrow), and prefrontal cortex (light blue arrow). b) PAE subject group map (z=59) showing activation in the superior and intraparietal lobes (red arrow). c-e) Control subject group maps (z=7, 17, 59, respectively) showing activation in the right and left temporal lobes (green) and prefrontal cortex (light blue). Activation threshold was p<0.005, with a cluster threshold of at least 300 connecting voxels.

21. Dysmorphia, Math and Reading

22. Components of Early Math Skills • Counting (naming, sequence) • Counting (enumeration) • Counting (cardinality) • “Counting on” • single item versus “composite” • place value rule

23. Components of the Math Intervention • Caregiver training • Manual regarding math development and FAS • Individual discussion regarding implementation of home math stimulation activities • Child tutoring • 6 week IEP developed using curriculum • 6 week 1 on 1 tutoring sessions • Teacher training • Manual regarding FAS • Discussion regarding child’s neurodevelopmental profile • Discussion regarding our 6-week IEP

24. Some of the Intervention Strategies Used • Behavioral Regulation for Parents • The Special Educators role • The behavior “techs” • Math Strategies • Teaching graphomotor skills

25. The Special Educator’s Role • Consult with parents re schools and concerns • Observe child’s learning/interaction style during pre-testing • Make recommendations for Report to school • Develop Project IEP for Math Intervention • Attend School IEP meeting • Provide training to teachers/school re FAS instruction • Consult with parents/teachers • Observe Behavior Techs and provide feedback • Change Math Intervention as necessary

26. Selecting Intervention Topics • Pretest to Identify deficits in basic skills • Operations on Collections of Objects (e.g., sorting) • Number and numerical operations (e.g., subtraction) • Geometry and space (e.g., shapes) • Measurement of continuous quantity (e.g., more/less) • Movement, time, and speed (e.g., duration) • Language, symbols and graphing (e.g., +, -) • Graphomotor/writing

27. Selecting Intervention Topics

28. IEP GOALS FOR #0116-WEEK TUTORIAL SESSIONS At the end of the 6-week tutorial sessions #011 will be able to: • Correctly print the numbers from 1 to 10 without reversals. • Correctly describe “same-different”, “more-less” of two objects or collection of objects. • Correctly identify spatial relations such as up-down, over-under, beside-between, left-right. • Correctly identify and name: square, circle, triangle and rectangle. • Continue a pattern of three or four items. • Correctly sort and classify groups according to different dimensions • Correctly order a group of objects by height, color, number and describe the sets by ordinality (first, second and third) • Understand the underlying concepts of addition (get more) and subtraction (get less). • Addition sums up to 5, using manipulatives and counting. • Write the number sentences for sums up to 5. Materials to help #011 achieve his goals: ·    Handwriting without tears – writing numbers ·        Activities: Level K: 69, 71, 74, Level 1: 97, 106, 107, 108, 109, 110, 117, 125

29. Sample Curriculum Page

30. Sample Parent Handout

31. Supports for visual-spatial deficits in the area of math

32. Graphomotor Deficit: “Handwriting w/o Tears” • UniformStarting point • Simplified Numbers use very basic lines and curves • Specific stroke sequence form the numbers • Developmental sequence in learning number formation (i.e.., use puzzle pieces made up of simple lines and curves to form the letters, draw on marked chalkboard with raised side)

33. Outcome Measures • Satisfaction-likert scale responses • Treatment and FAS Knowledge-multiple choice format • Compliance-attendance, compliance with data sheets, self-report of implementation • Family Functioning-PSI • Behavioral functioning-CBCLs • Supplemental Math • TEMA-2 (parallel forms) • Key-Math R/NU (parallel forms) • TERA-3 (parallel forms)

34. SAMPLE CHARACTERISTICS

35. Outcome Measures • Satisfaction-Likert scale responses • Treatment and FAS Knowledge-multiple choice format • Compliance-attendance, compliance with data sheets, self-report of implementation • Family Functioning-PSI • Behavioral functioning-CBCLs

36. Caregiver Workshop Feedback: Process Evaluation

37. Caregiver Workshop Feedback

38. Academic Outcome Measures • Supplemental Math • TEMA-2 (parallel forms) • Key-Math R/NU (parallel forms) • Number Writing Skill • Bracken Math subtests • TERA-3 (parallel forms)

39. Individual Scores on Verbal and Nonverbal Cluster Scores

40. Individual Scores on Letter Span and Spatial Span

41. Math Outcomes at Post 1:Multivariate Analysis of Variance on Change in Math Skills

42. Math Outcomes at Post Test 1 (χ=5.5, p < .02)

43. “Handwriting without Tears” with FASD Pretest: Writing Skills Post-test 2 Child’s age-6 years, 4-months at 1st post-test