Running head: FAS, A CASE STUDY

Best Practices in Designing, Implementation, and Evaluating Interventions: Fetal Alcohol Spectrum, A Case Study Angela Chiasson University of Calgary, Alberta APSY 658

FAS, A CASE STUDY Best-Practice Interventions for those with Fetal Alcohol Spectrum

Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe the entire continuum of effects that may result from prenatal alcohol exposure (as cited in Rasmussen, 2005). Prenatal damage is on a diverse continuum, from mild intellectual and behavioural issues to profound disabilities. There are five classifications used with regards to prenatal alcohol effects which include: 1) Fetal Alcohol Effect (FAE); 2) Fetal Alcohol Spectrum (FAS); 3) Partial Fetal Alcohol Spectrum (pFAS); 4) Alcohol Related Neurodevelopmental Disorder (ARND); and 5) Alcohol Related Birth Defects. Prenatal alcohol damage varies due to volume ingested, timing during pregnancy, peak blood alcohol levels, genetics and environmental factors. Prenatal alcohol exposure has been linked to more than sixty disease conditions, birth defects and disabilities and is one hundred percent preventable. Approximately 10-15% of Canadian school-aged children receiving special education services for causes by prenatal alcohol exposure (Fetal Alcohol Disorders Society, 2011). FASD is grossly under-diagnosed, one of the reasons being that few physicians have been trained to screen and diagnose for this disorder. Furthermore, there is no blood test, and no genetic marker alone that can prove a person has FASD. Instead, a diagnosis is based on the combination of knowledge of the mothers drinking behaviour, the childs behaviour patterns, neurodevelopmental characteristics, and characteristic facial features (Fetal Alcohol Disorders Society, 2011).

FAS, A CASE STUDY FASD is a term used to describe neurological and physical changes in patterns of brain damage associated with fetal exposure to alcohol during pregnancy. Brain structural abnormalities and neurocognitive dysfunction have been observed in individuals with FASD (Sowell et al., 2008). A study by Swayze et al. (1997) used magnetic resonance imaging with 10 children who met criteria for

FAS to compare total brain tissue with that of a healthy child, adolescent and control subjects. It was reported that patients with FAS have a high incidence of severe central nervous system anomalies (Swayze et al., 1997). Researchers have proposed that working memory may be the core deficit in those with FASD (Kodituwakku, 2010; Watson & Westby, 2003). The evidence for neuroplasticity in early brain development suggests that early intervention for children with FASD may present critical opportunity to remediate some of the brain damage done by prenatal alcohol exposure (PAE) (Paley & OConnor, 2009). Often, those with FASD are not diagnosed until they are school-aged, suggesting that by the time these children are diagnosed, an important window of opportunity for early intervention has been missed (Paley & OConnor, 2009). Other research suggests that with appropriate interventions, it is possible to remediate some of the effects of PAE (Watson & Westby, 2003). Research has found that individuals with FASD may have problems with measures of cognitive flexibility, working memory, inhibition, problem solving, fluency, organization and planning, abstract reasoning, and self-monitoring (Rasmussen, 2005; Watson & Westby, 2003). Individuals with FASD exhibit deficits on many aspect of executive functioning (Rasmussen, 2005). The present paper

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discusses interventions related to nonverbal working memory executive functioning deficits while analyzing a case study using Upah and Tillys (2002) 12 quality indicators for best practices in designing, implementing, and evaluating quality interventions. It is important to keep in mind that there is a need for more research-based interventions for children with FASD (Bohjanen et al., 2009). Case Study Tommy is a nine-year-old, Aboriginal boy, living in a small community on a reservation in British Columbia with his foster parents. Tommys birth mother, due to her age, emotional problems, and heavy alcohol use was unable to care for him. Child Protective Services found that Tommy was neglected as a baby and he was placed in foster care at the age of 13 months. Throughout Tommys developmental history, he was, and currently is very small for his age, falling below the 10th percentile. He has a small groove above his thin upper lip. He showed significant developmental delays in walking and talking. Academically, he is behind in many aspects compared to his peers. He has difficulty following directions, staying focused and completing assigned tasks. Tommy struggled upon entering Kindergarten because the environment was not as structured as his home environment. Throughout the next 4 years of school, teachers described him as having difficulty listening, staying focused and engaging with others. He was also described as lacking understanding to what was being said to him and difficulty with abstract reasoning, concepts of time and understanding figures of speech. At the age of five, Tommy was classified as having Fetal Alcohol

FAS, A CASE STUDY Spectrum (FAS) because he met the definition as having confirmed alcohol exposure, facial anomalies, growth retardation, and CNS dysfunction. Tommy has many strengths, including high verbal ability, good athleticism,

helpfulness, generosity, and is good with younger children. The school psychologist on Tommys case was Ms. Angela Chiasson. Problem Identification Behavioral Definition - What is the behaviour of concern (Upah & Tilly, 2002)? It was first evident that Tommy was different than other children his age when he was not walking and talking at the developmentally appropriate milestones. As time went on, Tommys teachers and foster parents were increasingly concerned about his lack of cognitive flexibility, difficulty with attention, and struggles with understanding new concepts. Teachers stated that Tommys level of performance was below that of his same aged peers. There was a noticeable difference between what was expected and Tommys actual performance. Having problems with nonverbal working memory means that Tommy has a lack of ability to recognize the relationship of present events to previous experiences (Watson & Westby, 2003). Examples of nonverbal working memory deficits include 1) difficulty remembering events or information; 2) difficulty imitating complex sequence of behaviors; 3) diminished sense of time; 4) limited self-awareness; and 5) defective hindsight and forethought (Upah & Tilly, 2002; Watson & Westby, 2003). The present case study focuses on Tommys difficulty with remembering events or information. Baseline Data

FAS, A CASE STUDY What is the students current level of performance in the target behaviour ? (Upah & Tilly, 2002) In order to collect baseline data, Ms. Chiasson went into Tommys classroom to observe him in a natural setting. It was clear that Tommy had difficulty remembering information that was presented to him. Ms. Chiasson observed Ms. Love give 6 instructions for a task and once Tommy got to the second step, he had difficulty remembering what to do next.

Problem Validation - How does the students behaviour compare to peers behaviour or environmental expectations? (Upah & Tilly, 2002) Most other students in the classroom were able to follow through up to step 5, without struggling. Whereas, when Tommy got to step 2, he looked confused and anxious about not knowing what to do next. Problem Analysis Steps 1 & 2: Collecting data (instruction, curriculum, environment, and the learner) and gathering information through observations and tests Ms. Chiasson went into Tommys classroom on three separate occasions to observe his behaviour in a natural setting. While Ms. Chiasson was in the classroom, she was able to make observations about the classroom setting, including organization, classroom size, supports, and seating. Furthermore, Ms. Chiasson was able to make observations about the curriculum and how it was being delivered to the students. Ms. Chiasson observed Tommys teacher, Mrs. Jennifer Loves style of teaching to see if she was differentiating to the needs of each child, since all children learn differently, particularly Tommy. In addition, Ms. Chiasson went to the school

FAS, A CASE STUDY office to gather current and previous information from his cumulative file.

Important information that was gathered from the cumulative file included some of Tommys family history and background, as well as his academic progress. Ms. Chiasson was able to meet with the Tommys teacher, Mrs. Love, once to discuss his progress and any concerns from the teacher perspective. Ms. Love also discussed what strategies she has tried in the classroom with Tommy, making reference to what has been successful and what has not been successful. Tommys foster parents, Mr. John Cabot and Mrs. Judy Cabot, were happy to meet with Ms. Chiasson to discuss further into Tommys family history and background. Appendix A shows an overview of questions that were asked when Ms. Chiasson met with Mr. and Mrs. Cabot. Mr. and Mrs. Cabot, along with Mrs. Love were asked to complete the Conners, third edition to help assess Tommys behaviour related to inattention, hyperactivity/impulsivity, learning problems, executive functioning, aggression and peer relations. Mr. Cabot, Mrs. Cabot and Mrs. Love rated Tommy in the Very Elevated range for executive functioning. Furthermore, all three raters indicated that Tommys behaviours fell within the Very Elevated range for learning problems. Step 3: Hypothesis generation/prediction statement If Ms. Love uses visuals paired with verbal instruction, checklists and encourages Tommy to self-monitor, then Tommys capability to remember instruction will increase. Step 4: Hypothesis validation

FAS, A CASE STUDY Date was collected through observation and checklists to confirm the prediction statement. Step 5: Focus on intervention and design The first step to designing an intervention for Tommy was to fill out a Functional Behaviour Assessment (FBA) form (see Appendices B and C for an example consent form and FBA). Also, a curriculum-based evaluation (CBE) was used to examine assumed causes of problem behaviours linking assessment to

instruction (Upah & Tilly, 2002). Intervention goals for nonverbal working memory include developing nonverbal representations of actions and events as well as providing a structured environment with visual cues to support behaviour (Watson & Westby, 2003). Plan Implementation Goal Setting - What is our desired outcome of the intervention? (Upah & Tilly, 2002) When setting goals for Tommy, it was important to ensure that they were meaningful and measurable. Example of one goal for Tommy can be as follows: Goal 1: In eight weeks, when the teacher presents gives instruction, Tommy will recall 50% of the information. Intervention Plan Development - What are we going to do to achieve that outcome? (Upah & Tilly, 2002) Ms. Chiasson made the following intervention recommendations to Mrs. Love to try in the classroom: 1) Visualization training to support Tommys difficulties with nonverbal working memory deficits; 2) Self-awareness training, such as videotaping and corrective feedback was to increase Tommys self-awareness; 3) A

FAS, A CASE STUDY consistent and structured environment to help Tommy remember specific information to help follow routines and know what to expect; 4) Use of repetition and consistency; 5) Visual cues; 6) Visual schedules; 7) A timer; and 8) Checklists

were also recommended to help Tommy remember information, expect transitions, and stay organized (see Appendix D for examples of visual recommendations) (Watson & Westby, 2003). Measurement Strategy - How are we going to know if the plan is working? (Upah & Tilly, 2002) In the classroom, Ms. Love will teach Tommy to monitor his progress by using personal checklists. She will also use checklists to monitor Tommys progress to know if the plan is working, so that Tommy can show understanding. In addition, questioning Tommy for understanding will be another form of collecting data. If Tommy is able to repeat back, and follow through on 50% of the instruction, then it will be evident that he is progressing. Ms. Love has been advised to graph the data that she collects from Tommys progress to have a clear visual of his progress. The data will be collected three times per week. Decision-Making Plan - What do we do if the plan works or does not work? (Upah & Tilly, 2002) If all steps of the plan are followed properly and Tommy is not reaching his goals then the plan must be modified so that he can be successful. For example, if Tommy is unable to recall 50% of the information, the plan might be modified for him to recall 25% of the information and then slowly move up to 50%. Another way to modify the goal is to add the words with cueing, so that Tommy is able to recall

FAS, A CASE STUDY 50% of the information with cues. Once he has reached that goal, the teacher can slowly take away the cues and change the goal to reflect the Tommys progress while challenging him to reaching a harder goal. Program Evaluation Progress Monitoring - Is the intervention working? (Upah & Tilly, 2002) Graphing Tommys performance enabled the Ms. Chiasson and Ms. Love to

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detect slight changes in behaviour that might otherwise not be recognized (Upah & Tilly, 2002). Use of checklists, portfolios, rubrics, and observation procedures were used to monitor Tommys progress. Formative Evaluation - Is the plan working? (Upah & Tilly, 2002) Throughout the formative evaluation stage, it was determined if the interventions needed to be modified to increase the likelihood that Tommy would reach his goal of recalling 50% of the instruction presented to him. Treatment Integrity - Is the intervention being implemented as planned? (Upah & Tilly, 2002) Ms. Chiasson gave Ms. Love a written intervention plan so that she could follow the proper interventions. To assess treatment integrity, Ms. Chiasson visited Tommys classroom once a week for direct observation of Ms. Loves behaviour to ensure that she is carrying out the interventions as planned. Summative Evaluation - Did the intervention work? (Upah & Tilly, 2002) After eight weeks of intervention, it was found that Tommy was able to recall 50% of the instruction presented to him. The interventions that Ms. Chiasson and Ms. Love put into place were successful and produced positive outcomes for

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Tommy, especially using visuals as reminders and repetition. The next goal on the intervention plan is for Tommy to recall 75% of the information presented to him. Summary and Concluding Discussion Upah and Tillys (2002) 12 quality indicators of Best Practices in Designing, Implementing, and Evaluating Interventions is a great step-by-step resource to help guide effective interventions to meet the needs of all students. The present paper reviews interventions related to modification of the students behaviour and environment. There are many kinds of interventions available that were not mentioned in this paper, including cognitive, parent focused, social skills training, pharmacological and adaptive skills training. For overall success in all areas, it is recommended that those working with children with EF deficits caused by FASD to analyze all options available while keeping the child in mind. It is important to think of Tommy as a child first, and to refrain from stereotypes and judgments about the disorder. All children, including Tommy, have strengths and it is important to build upon these strengths while recognizing how to accommodate for the weaknesses. All of those involved in Tommys case must have the expectation that the child will succeed, and act as his personal cheerleader. Furthermore, educators should not assume that every child who exhibits executive functioning difficulties has been exposed prenatally to alcohol and other drugs, but recognizing the characteristics of executive dysfunction, regardless of its cause, is essential if students are to receive appropriate interventions (Watson & Westby, 2003). There continues to be little knowledge about the effectiveness of FASD interventions, which leads to the need for future research in this area.

FAS, A CASE STUDY Appendix A

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Questions to Discuss During Meetings with Parents (BC Ministry of Education, 2004) General Information What do you think is important or me to know about your child, e.g., specific health problems, such as seizures, vision/hearing problems, heart problems, medications? What educational and social goals do you have for your child? When other children ask about your childs differences, what do you say?

Communication and Adaptations Did your child attend a special needs preschool? Has your child receive special services in school before? Does your child require special therapy outside of the school, such as speech/language, occupational/physical, counseling? What are some strategies you have found useful in working with your child?

Behaviour What interests, activities, or hobbies does your child enjoy? Could you tell me about your childs behaviour challenges and what this might mean in the classroom? What causes your child to feel overwhelmed? How does your child react when he is frustrated or over stimulated?

Assessment and Evaluation Are there any reports or other information about your child that are important for me to have? Is your child able to work independently? For how long? In what areas has your child experienced particular success? What areas would you most like your child to succeed in this year?

Home and School Is there further information you feel I should know about the child, e.g. recent changes in the childs life, history of the childs living arrangements? How can we work together to help your child learn? Are there ways we can create consistency at home and school? Are there any questions your would like to ask me?

FAS, A CASE STUDY Appendix B Functional Behaviour Assessment Consent Form

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A behavior assessment is intended to help your childs teacher(s) understand and plan for your childs behavioral needs. Therefore, we are requesting your permission to conduct a Functional Behavior Assessment. This assessment is based on an interview with the student and classroom observations. You may also be asked for your input. Once the assessment in completed, the Behavioral Support/Learning Support Staff will be able to structure a Behavior support plan that will focus on positive intervention strategies for your child. Please complete the bottom portion and return it to your childs school. If you have any further questions prior to signing this form, please contact Ms. Chiasson, at angelachiasson@hotmail.com.

Print Childs Name ____________________________ Birth Date: _________________________________ Alberta Student Number: ___________________________________________________________________ o I hereby consent for my child to receive a behavior assessment to support my childs learning. o I do not provide consent for my child to receive an assessment because __________________________________________________________________________________. Parent Signature: _____________________________________________________________________

FAS, A CASE STUDY Appendix C Example of Functional Behaviour Assessment (FBA) Student Name: __________________________ID: _________________ DOB: ________________ Case Manager: _______________________ Data Sources: Observation | Student Interview | Teacher Interview | Parent Interview | Rating Scales | Normative Testing Description of Behavior (No. ____):

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Setting(s) in which behavior occurs:

Frequency:

Intensity (Consequences of problem behavior on student, peers, instructional environment):

Duration:

Describe Previous Interventions:

Educational impact:

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Function of Behavior (No. ____): Specify hypothesized function for each area checked below. Affective Regulation/Emotional Reactivity (Identify emotional factors; anxiety, depression, anger, poor self-concept; that play a role in
organizing or directing problem behavior):

Cognitive Distortion (Identify distorted thoughts; inaccurate attributions, negative self-statements, erroneous interpretations of events;
that play a role in organizing or directing problem behavior):

Reinforcement (Identify environmental triggers and payoffs that play a role in organizing and directing problem behavior):
Antecedents: Consequences:

Modeling (Identify the degree to which the behavior is copied, who they are copying the behavior from, and why they are copying the
behavior):

Family Issues (Identify family issues that play a part in organizing and directing problem behavior):

Physiological/Constitutional (Identify physiological and/or personality characteristics; developmental disabilities, temperament; that
play a part in organizing and directing problem behavior):

Communicate need (Identify what the student is trying to say through the problem behavior):

Curriculum/Instruction (Identify how instruction, curriculum, or educational environment play a part in organizing and directing problem
behavior):

FAS, A CASE STUDY Appendix D Examples of Visuals for Classroom Routines, Organization, and Checklist

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FAS, A CASE STUDY References Alberta Education (2004). Teaching Students with Fetal Alcohol Syndrome: Building Strength and Creating Hope. Edmonton, AB.

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Bohjanen, S., Humphrey, M. & Ryan, S.M. (2009). Left Behind: Lack of Research-Based Interventions for Children & Youth with Fetal Alcohol Syndrome Disorders. Rural Special Education Quarterly, 28, 32-37. Kodituwakku, P. W. (2010). A neurodevelopmental framework for the development of interventions for children with fetal alcohol spectrum disorders. Alcohol, 44, 717728. doi 10.1016/j.alcohol.2009.10.009 Paley, B., & OConnor, M. J. (2009). Intervention for individuals with fetal alcohol spectrum disorders: treatment approaches and case management. Developmental Disabilities Research Reviews, 15: 258-267. Doi: 10.1002/ddrr.67. Rasmussen, C. (2005). Executive functioning and working memory in fetal alcohol spectrum disorder. Alcoholism: Clinical and Experimental Research, 29(8), 1359-1367. doi: 10.1097/01.alc.0000175040.91007 Ritchie, B. (2011). FASlink Fetal Alcohol Disorders Society, Research, Information, Support and Communication. Retrieved from http://www.faslink.org/ Sowell, E. R., Johnson, A., Kan, E., Lu, L. H., Van Horn, J. D., Toga, A. W., OConnor, M. J., Bookheimer, S. Y. (2008). Mapping white matter integrity and neurobehavioral correlates in children with fetal alcohol spectrum disorders. The Journal of Neuroscience: The Official Journal of the Society for Neuroscience. Vol. 28, p. 1313-1319.

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Swayze, V. W., Johnson, V. P., Hanson, J. W., Piven, J., Sato, Y., Giedd, J., Mosnik, D., Andreasen, N. C. (1997). Magnetic resonance imaging of brain anomalies in fetal alcohol syndrome. American Journal of Pediatrics. Vol.99, p. 232-240. doi: 10.1542/peds.99.2.232. Upah, K. R. & Tilly, W. D. (2002). Best Practices in Designing, Implementing, and Evaluating Quality Interventions. Watson, S. M. & Westby C. E. (2003). Strategies for Addressing the Executive Function Impairments of Students Prenatally Exposed to Alcohol and Other Drugs. Communication Disorders Quarterly, Vol. 24, 194-204.