Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

A Review of: Math Performance and Behavior Problems in Children Affected by Prenatal Alcohol Exposure: Intervention and Follow-Up Claire D. Coles, Julie A. Kable, Elles Taddeo

Elaine Bolt, Monique Janssen, and Pasquale Veleno

Submitted to Dr. Trista Knoetzke ASPY 674 Winter 2010 University of Calgary

March 20, 2010

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD A Review of: Math Performance and Behavior Problems in Children Affected by Prenatal Alcohol Exposure: Intervention and Follow-Up

Prenatal alcohol exposure (PAE) has been recognized for almost 40 years as contributing to many lifelong physical and developmental challenges. Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term used to describe a number of brain-based disorders caused by PAE to the developing fetus (Streissguth, 1997). There are four main diagnostic categories: Fetal Alcohol Syndrome (FAS), partial Fetal Alcohol Syndrome (pFAS), Alcohol Related Neurodevelopmental Disorder (ARND) and Alcohol Related Birth Defects (ARBD) (Streissguth). Health Canada (2004) indicates, FASD is the leading cause of mental retardation in the Western world affecting approximately 1% of Canadians (p. i). Cognitive concerns related to PAE include speech and language disorders and / or expressive language delays, mathematical deficiencies, difficulty with abstraction, problems generalizing one situation to another, poor attention and concentration skills, memory deficits, underdeveloped skills, and impaired judgment and abstract reasoning (Streissguth). The cognitive deficits associated with FASD have a significant impact on academic outcomes, and place these alcohol-affected children at high risk for academic failure (Streissguth). Furthermore, children with FASD typically present with significant behavioural challenges that require intervention (Stratton, Howe & Battalion; 1996). While primary disabilities, including characteristic growth patterns, physical features and neurodevelopmental issues are readily apparent upon school entry, many secondary disabilities do not become evident until the child enters into adolescence. These secondary disabilities may contribute to legal troubles, disrupted school experience, or substance abuse problems. In a 20-year study, Streissbuth (1997) found over 50% of individuals with FASD showed signs of these secondary issues. Moreover, children with

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

FASD have high rates of comorbidity with ADHD, various learning disabilities, anxiety disorders, and behavioral concerns. There is a scarcity of research on school-based interventions specifically targeted for children diagnosed with FASD. Coles, Kable, and Taddeo (2009) acknowledge there is limited information specific to this disorder than can serve as a guide to professionals and parents in planning for educational interventions (p. 7). As such, the authors developed a psychoeducational program aimed at addressing the cognitive and behavioural deficits specific to this population. The intervention utilized by the authors incorporated both home and school-based components. This intervention the dependent variable - focused on improving math learning and performance in children with FASD. Specifically, the authors wanted to evaluate: 1) whether the effects of math intervention persist after the end of active treatment; and, 2) whether behavioural changes noted by caregivers are also observed within the school setting. The purpose of this review therefore, is to examine the study by Coles et al. (2009) that compared the efficacy of the math intervention program to a standard psychoeducational group as it pertains to math performance, learning readiness, and behaviour. Intervention The authors developed a program called the Math Interactive Learning Experience (MILE) to improve premath readiness and math skills in children from three to ten years. This intervention included both caregiver and in-school components, and attempted to equip caregivers with the skills necessary to support childrens self-regulation while teaching children to achieve readiness to learn prior to the introduction of math instruction. Children were assessed using standardized math assessments, including the Test of Early Mathematical Ability, Second Edition, Bracken

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

Early Concept Scales Revised, Keymath R/NU, and a Number Writing Task, before and after the intervention (Coles et al., 2009). Two other elements were included in the delivery of the intervention. The first was a learning approach adapted from the plan-do-review methodology developed by the High-Scope Perry Preschool Project (Coles et al., 2009, p. 8). The second element was the inclusion of materials from the Handwriting Without Tears program (Coles et al.). The MILE program lasted six weeks and caregivers and teachers were asked to rate the childs behavior both before and after the intervention using the Child Behavior Checklist (CBCL) and Teacher Report Form (TRF), respectively. Methods and Design Eighty-seven children and their caregivers were recruited from the Atlanta metropolitan area in an initial study completed by the authors. Many participants were specifically recruited from a local multidisciplinary clinic offering services to alcohol and drug-exposed children, while other participants were gleaned via community notices in newspapers, mailings to schools and pediatricians, and talks at local meetings by study staff. All participants were required to have a clinical FAS or partial FAS diagnosis or significant levels of alcohol-related dysmorphology, as determined by a geneticist using a dysmorphia checklist. Children were not eligible if they had an IQ score less than 50, were diagnosed with mental health problems affecting learning, or were not in a stable home environment (Coles et al., 2009). Readiness to learn in children was established by having caregivers attend two workshops: one detailing the neurocognitive impact of FAS, and special education and advocacy issues; the second to provide caregiver training specific to promoting behavioural regulation in children (Coles et al., 2009). Prior to workshop introduction, children in the study received a neurodevelopmental evaluation, consisting of administration of the

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

Differential Abilities Scales to determine cognitive functioning, Beery-Buktenica Developmental Test of Visual Motor Integration to evaluate graphomotor function, and elements of the NEPSY to assess visual attention. Furthermore, caregivers and teachers completed behaviour and demographic questionnaires. Collected data were used as baseline measures. After completing the screening process, participants were randomly assigned to one of two groups: the Math Interactive Learning Experience group (MILE), or the standard psychoeducational contrast group, which consisted of a comprehensive neurodevelopmental evaluation and IEP support (Coles et al., 2009). Those participants within the math intervention group received 6-weeks of tutoring services, including individualized caregiver instruction aimed at supporting math learning at home, and home assignments, in conjunction to the services and supports provided to the contrast group. Though not explicitly stated, the processes described within this stage appear consistent with a between-subjects experimental design, using a randomized controlled trial. Assessments were completed after six months subsequent to the completion of the intervention phase. In an attempt to control for time variables, the authors ensured that a corresponding child from the contrast group was always assessed during the same week that a child within the intervention group was assessed. Children were evaluated by a psychologist or psychology graduate student blind to participant group assignment (Coles et al., 2009). Caregivers and teachers completed follow-up questionnaires. It should be noted that, given the passage of time, most of the teachers required to complete the follow-up questionnaires were different than the teachers who originally completed the (pre-intervention) questionnaire, while only 74% of the teachers queried returned questionnaires.

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

Caregivers were required to rate their satisfaction with their respective programs using a Likert scale. Furthermore, teachers and caregivers were required to complete behavioural outcomes measures, i.e., using the Child Behaviour Checklist and Teacher Rating Form, respectively. Lastly, academic measures such as the Test of early Mathematical Ability, second edition; Bracken Early Concept Scales Revised; and Key Math-R/NU (for children five years of age and over), were administered and compared with baseline measures. Quality of number writing was also assessed using a seven item number writing instrument developed by the authors, and used to assess order, orientation, neatness, consistency, and general recognizability of the numbers (Coles et al., 2009). Outcomes The results from this short study led the researchers to question whether the positive effects of the intervention would persist after a period of time and if the behavioral changes noted by parents would be observed in other settings, like the school (Coles et al., 2009). This portion of the study was carried out six months after the intervention ended. The childs teacher was asked to rate the childs behavioral functioning within the classroom. It was hypothesized that learning readiness would be maintained causing the childs math performance to continue to improve, even six months after the conclusion of the formal intervention. Additionally, parent and teacher ratings of the childs behavior were expected to improve over the six month follow up. Fifty-four participants fulfilled the study requirements necessary for study completion, and this number constitutes the final sample size. Caregivers from both groups reported comparatively high levels of satisfaction with the Math Interactive Learning Experience (MILE) program, and indicated a mutual improvement in their knowledge of fetal alcohol syndrome, behaviour regulation and advocacy skills (Coles et al., 2009).

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

Math performance and learning readiness are the dependant variables in this study. Once controlling for math functioning pre-intervention and overall intellectual ability, participants within the math intervention group made significantly larger gains compared with the contrast group (68.4% vs. 38.5%, respectively). Gains were operationalized by performance increases of one and a half standard deviation units above the group mean. Furthermore, 25% of the participants within the math treatment group made a clinically significant gain on two or more math measures, compared with 16% within the contrast group, while 39% within the treatment group made a gain on one measure compared with 24% within the contrast group (Coles et al., 2009). No effects were noted for the treatment group regarding readiness to learn, as measured via caregiver completion of the CBCL, though post hoc comparisons noted that children aged three to five years of age had a greater reduction in behavioural problems than did older children (Coles et al., 2009). Implications for Practice The MILE intervention was found to positively affect childrens mathematics performance; while both the MILE intervention and control condition led to improved caregiver rating of childrens behavior (Coles et al., 2009). This indicated that the educational workshop provided to all participants parents, which focused on increased knowledge of the disorder and methods for managing child behavior, was effective. However, some weaknesses with this study lead to questions about its utility as an everyday intervention. For instance, the intervention is not described in enough detail in either of the original or six month follow up reports for it to be recreated in a school (Coles et al.; Kable, Coles, & Taddeo, 2007). Additionally, the efficacy of the intervention varied by age of the child, severity of the childs symptoms, age of the primary caregiver, and size of the family but results were not reported by any of these factors (Coles et al.). This makes it difficult to determine exactly who would benefit from the math intervention.

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

Another research to practice gap with this intervention is that participants were somewhat selfselected and met certain inclusion criteria; which means they differ from the general population of children with FASDs who are more likely to have a comorbid disorder and less involved parents (Coles et al., 2009). A final research to practice gap lies in the use of one-on-one instructional programming for mathematics tutoring which is likely to be prohibitively expensive for schools (Kable et al., 2007). Implications for Research While some research to practice gaps exist, the MILE intervention follows much of the best practice research established for children with FASD. Unfortunately, little research has been conducted on interventions for children with FASD and what does exist is mostly gleaned from interventions used with people with other disabilities, practical wisdom gained from experienced parents and clinicians, or on heterogeneous samples from South Africa (Bertrand, 2009). Of the North American research that exists the use of parent information sessions to educate parents on FASD associated deficits, behavior management strategies, and methods of advocating for the childs needs have been proven effective in all studies (Bertrand; Coles et al., 2009; Kable et al., 2007). Parent training was provided in both conditions in this study and parents reported feeling more competent and noticed fewer behavior problems as a result of this training (Coles et al.). However, this training further supports an FASD intervention model wherein interventions occur in the home environment and are aimed at the parents. The focus on a school based mathematics intervention in the present study is a positive addition to the current research body.

References

Running head: MATH PERFORMANCE AND BEHAVIOR IN FASD

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. Coles, C.D., Kable, J.A., & Taddeo, E. (2009). Math performance and behavior problems in children affected by Prenatal Alcohol Exposure: Intervention and follow-up. Journal of Developmental Behavioral Pediatrician, 30, 7-15. Health Canada. (2004). Fetal Alcohol Spectrum Disorder knowledge and attitudes of health professionals about Fetal Alcohol Syndrome: Results of a national survey. Ottawa, ON: Public Health Agency of Canada. Kable, J.A., Coles, C.D., & 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. OMalley, K. D., & Nanson, J. (2002). Clinical implications of a link between Fetal Alcohol Spectrum Disorder and Attention-Deficit Hyperactivity Disorder. The Canadian Journal of Psychiatry, 47(4), 349-354. Stratton, K., Howe, C., & Battalion, F. (eds.). (1996). Fetal Alcohol Syndrome: Diagnosis, epidemiology, prevention and treatment. Washington, DC: National Academy Press. Streissguth, A. (1997). Fetal Alcohol Syndrome: A guide for families and communities, Baltimore, MD: Brookes Publishing Company.