# Presentation: 363823

## Fetal Alcohol Syndrome:Socio-Cognitive Habilitation

**Claire D. Coles, PhD**
**Julie A. Kable, PhD**
**Douglas Lee, MD**

## The Marcus Intervention Project is one of five intervention sites focusing on FASD

- Centers for Disease Control and Prevention (CDC)

- UCLA

- UWA

- Chicago

- UOKLA

## 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****.**

## 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.

## 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

## 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

## 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

## 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)**

## Intervention Study Design

**0****1****=Pre-testing**
**A=Caregiver advocacy training**
**B=Learning readiness**
**C=Math intervention**
**O****2****=8-wk Post-testing**
**O****3****=6-mo Post-testing**

## Learning Readiness

**Parent Education about FAS**
**Case/Social Service Management**
**Psychiatric Evaluation/Medication Management**
**Neurodevelopmental Evaluation**
**Educational Management**
**Behavioral Regulation Training**

## Case Management Services

**Assistance with transportation**
**Assistance with finding appropriate therapeutic services for the child**
**Assistance with obtaining appropriate parental support services**

## Psychiatric Evaluation

- Evaluation and assessment to determine appropriateness and efficacy of any medications
- Determine the need for any behavioral/emotional therapy

## Prevention of Barriers

- Transportation if needed
- Flexible work hours
- Free babysitting
- Reimbursement for gas

## 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**

## Group Administered Parent Education 

- Understanding 	FASD
- Caregiver Advocacy 	Training
- Behavioral 	Regulation 	Training

## 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.**

## 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 **

## 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**

## Core Deficits Impact on Mathematical Thinking

**Visual-motor**

**Working memory**

**Global Deficits**
**  “****IQ”**

**Visual-spatial**

**Math**

**Prenatal **
**Alcohol**

##  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). 

-  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.

## Dysmorphia, Math and Reading

| Model | T-Score | Significance | Partial Correlation |
| --- | --- | --- | --- |
| Child’s Age | 13.873/14.39 | p<.000 | .87/.88 |
| Verbal IQ | 7.94/6.56 | p<.000 | .72/.65 |
| Dysmorphia
(Math) | -2.43 | P<.02 | -.30 |
| Dysmorphia
(Reading) | -.094 | ns | -.12 |

## Components of Early Math Skills

- Counting (naming, sequence)
- Counting (enumeration)
- Counting (cardinality)
- “Counting on”
- single item versus “composite”
- place value rule

## 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**** **

## Some of the Intervention Strategies Used

- Behavioral Regulation for Parents
- The Special Educators role
- The behavior “techs”
- Math Strategies
- Teaching graphomotor skills

## 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**

## 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**

## Selecting Intervention Topics

| “Strand” | Pre | Kg | 1 | 2 | 3 | 4 |
| --- | --- | --- | --- | --- | --- | --- |
| Operations on Collections of Objects |  |  |  |  |  |  |
| Number and Operations |  |  |  |  |  |  |
| Geometry and Space |  |  |  |  |  |  |
| Measuring Continuous Quantity |  |  |  |  |  |  |
| Movement, Time and Speed |  |  |  |  |  |  |
| Language, Symbols, Graphing |  |  |  |  |  |  |

## IEP GOALS FOR #0116-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**

## Sample Curriculum Page

**Sample Curriculum Page**

## Sample Parent Handout

**Sample Parent Handout**

## Supports for visual-spatial deficits in the area of math

## Graphomotor Deficit: “Handwriting w/o Tears”

-  **Uniform** **Starting 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)**

## 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)**

## SAMPLE CHARACTERISTICS

| Variable | Math Intervention + Readiness to Learn Intervention Group | Readiness to Learn Intervention Group |
| --- | --- | --- |
| Sex: Percentage Male | 47.6 | 52.4 |
| Age | 7.1 (2.1) | 6.7 (2.2) |
| Race: %Caucasian | 62.5 | 62.5 |
| Percentage Adopted | 87.5 | 68.8 |
| Dysmorphia Score | 17.3 (4.6) | 15.9 (7.9) |
| DAS-GCA Score | 83.2 (8.9) | 85.3 (16.4) |
| DAS-Nonverbal Cluster  | 79.1 (8.8) | 88.1 (17.2) |
| DAS-Verbal Score | 90.8 (16.3) | 87.2 (16.7) |

## 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

## Caregiver Workshop Feedback: Process Evaluation

| Variable | Mean Level
N=91 | % Agree |
| --- | --- | --- |
| Therapist friendly and helpful | 3.9 | 100 |
| Therapist knowledgeable | 3.8 | 100 |
| Therapist encouraged questions | 3.8 | 97.6 |
| Therapist easy to follow | 3.7 | 98.9 |
| Materials useful/helpful | 3.7 | 96.7 |
| Materials easy  to understand | 3.8 | 100 |
| Information presented at good pace | 3.6 | 98.9 |

## Caregiver Workshop Feedback

| Variable | Math 
N=13 | No Math
 N=11 |
| --- | --- | --- |
| Program was informative | 92.3 | 90.9 |
| Program was helpful | 92.4 | 91.8 |
| Program improved my understanding of FAS | 92.4 | 91.0 |
| Program improved my knowledge of behavioral regulation | 76.0 | 72.8 |
| Program improved my knowledge of advocacy | 69.3 | 87.5 |
| Empowered me to ask for services | 61.6 | 72.7 |
| Improved my ability to resolve conflicts | 61.6 | 81.8 |
| Improved my ability to help child study | 77.0 | 45.5 |
| Improved child’s study habits | 71.6 | 36.4 |
| Would recommend the program | 84.6 | 90.9 |

## 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)**

## Individual Scores on Verbal and Nonverbal Cluster Scores

## Individual Scores on Letter Span and Spatial Span

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

| Variable | F-(value) | Significance | Partial Eta Squared | Effect Size Category |
| --- | --- | --- | --- | --- |
| Premath Functioning | F( 3,38)=3.6 | P < .02 | .222 | Medium effect |
| Math Intervention | F(3,38)= 2.9 | P < .05 | .188 | Medium effect |

## Math Outcomes at Post Test 1

|  | No Math

n=26 | Math Tutoring
n=29 |
| --- | --- | --- |
| No Gain | 84.6% | 55.2% |
| Gain
 (> 1 standard deviation on at least one measure) | 15.4% | 44.8% |

- (χ=5.5, p < .02)

- Child’s age-6 years, 4-months at 1st post-test

- Pretest: Writing Skills

- Post-test 2

- “Handwriting without Tears”  with FASD