Furthermore, caregivers in the FMF group reported significantly greater improvements in child behavior problems postintervention than did caregivers in the comparison group. The FMF program is notable for its intensive, sustained approach and focus on the larger family system, as well as broader systems of care.
Although some families of children with FASD might not require this level of intervention, there are undoubtedly many families who would benefit from having ongoing guidance in how to parent these children, particularly as their children navigate their way through increasingly complex developmental challenges. Moreover, although the FMF program is described in a written manual with session-by-session instructions for therapists to follow i.
This initial study validating the efficacy of FMF has laid the groundwork for efforts now under way to disseminate this approach into community settings. Recent studies have examined the efficacy of various approaches to addressing some of the cognitive, executive functioning, and behavioral impairments that interfere with learning and academic performance among children with FASD.
Such children show deficits in verbal and spatial learning, planning, working memory, cognitive flexibility, inhibition, and problem solving, as well as impairments in reading, spelling, and math skills Duquette and Stodel ; Green et al. High rates of learning disabilities Burd et al. Given these challenges, it is not surprising that students with FASD have high rates of disrupted school experiences e. Both clinicians and researchers have commented on the importance of modifying both teaching strategies and classroom environments in order to provide increased structure and support for children with FASD Green ; Kalberg and Buckley In addition to environmental adaptations that may be implemented in order to accommodate some of the cognitive and behavioral impairments of these individuals, a small but growing number of interventions have focused on enhancing either general learning skills or specific cognitive or academic skill sets.
Adnams and colleagues see Riley et al. The intervention consisted of cognitive control therapy CCT , which instructs children in strategies that facilitate their ability to acquire and organize information more effectively. The children were randomly assigned to either the intervention condition in one classroom in one school or to the control condition in another classroom in another school and were matched on age, grade, first language, socioeconomic statues, and locality of school. Children in the intervention condition received 1 hour of CCT per week from two trained, experienced therapists over the course of 10 months during the school term.
Compared with the control group, children who received CCT demonstrated marked improvements in classroom behavior. The intervention group also showed qualitative improvements in academic achievement, writing, and communication skills, according to teacher report; improvements in self-efficacy, motivation, self-confidence, and emotionality, according to therapist report; and general school achievement, attitude towards learning, and self-confidence, as reported by school staff. However, the CCT and the control group did not differ significantly from one another on cognitive control and neuropsychological measures.
Despite the limitations of the study described by the authors, including a small sample size and a shorter course of CCT than is typical, these initial findings are encouraging. Moreover, as the authors further note, future studies that implement CCT with younger children may be able to capitalize on greater brain adaptability and yield even stronger findings. Additionally, efforts to involve parents or other caregivers in the intervention by teaching them skills to help their children use cognitive control strategies in other settings also might enhance treatment outcomes.
In another study conducted in South Africa, Adnams and colleagues reported on the efficacy of a school-based language and literacy training LLT intervention for 9-year-old children with FASD. The study also included a control group of 25 children who were not exposed to alcohol. Children received two half-hour sessions of LLT twice weekly from an experienced speech and language therapist over the course of 9 months. Sessions were delivered in a group format in a school classroom, and children of similar abilities were assigned to the same group.
Compared with the FASD control group, the LLT group showed significant improvements after treatment in the domains of letter knowledge, syllable manipulation, word and nonword reading, and nonword spelling. However, after the treatment, the LTT group did not differ significantly from the FASD control group on measures of scholastic ability. Moreover, both FASD groups continued to lag significantly behind the nonexposed control group on scholastic measures. Such findings suggest that although it may be possible to enhance specific language and literary skill sets in children with FASD, these improvements may not translate into broader gains in academic achievement.
Additionally, these findings may highlight the difficulty of intervening with children in high-risk environments who are likely dealing with additional challenges beyond prenatal exposure e. This program was adapted to enhance self-regulation skills and remediate executive functioning deficits in 6- to year-old children who had been diagnosed with FAS or ARND and who had been adopted or were in foster care.
A total of 78 children were randomly assigned to either the intervention condition or to a control condition. The control group received a comprehensive evaluation and was referred to the community for services such as speech and language therapy, occupational therapy, and physical therapy. Children in the treatment condition also received a complete evaluation for treatment planning and participated in 12 weekly minute neurocognitive rehabilitation group-therapy sessions, whereas their parents participated in a parent education group.
Results revealed a significant treatment effect on a parent report measure of executive functioning see Bertrand Additional study of this intervention, including obtaining teacher and follow-up data, would help clarify whether these effects generalize to other settings e. Focusing more specifically on a learning disability often noted in children affected by prenatal alcohol exposure, Kable and colleagues developed a sociocognitive mathematics program for children with FASD.
Prior to assignment to treatment and control groups, all caregivers participated in two workshops in which they received education about FASD and instruction in how to promote positive behavioral regulation skills in their children. Participants were then randomly assigned to either a math intervention group or a control group.
Both the treatment and the control groups received a neurodevelopmental assessment, and caregivers received guidance in obtaining an appropriate educational placement and in developing an individualized education plan. Parents in both groups reported high levels of satisfaction with the workshops and showed significant improvements in their knowledge of FASD, advocacy topics, and behavioral regulation. Findings revealed that children who received the math intervention in addition to educational support demonstrated greater gains on mathematics outcome measures compared with those who received educational support only Kable et al.
In one of the few studies to examine the maintenance of treatment effects over time, Coles and colleagues found that children in the treatment group continued to show these gains at 6-month followup. To improve working memory among children with FASD, Loomes and colleagues developed an intervention to promote the use of rehearsal strategies. A total of 33 children were randomly assigned to a treatment or control group. Children in the treatment group were instructed to use a simple rehearsal strategy by whispering the items they would be asked to recall.
Children in the experimental condition demonstrated significant improvement in their scores on recalling a series of numbers i. In contrast, the control group showed no significant change in their scores across the three sessions. Moreover, although the treatment and control groups showed no differences in recall either prior to or immediately following instruction, the treatment group demonstrated significantly greater recall on the digit span task than the control group at the second posttest.
Furthermore, the treatment group exhibited behavioral evidence of increased use of rehearsal strategies e.
Similar to many treatment studies with this population, this study included a relatively small sample and did not follow the children over time. Future research in this area would help clarify whether children with FASD are able to maintain the use of a rehearsal strategy over a longer period of time and in other settings, such as in a classroom, where the demand for working memory is likely to be high. Educational and cognitively based interventions for FASD have yielded some limited but encouraging results, demonstrating that although the negative effects of prenatal alcohol exposure can be pervasive and severe, it seems possible to mitigate some of these impairments with treatment.
As most of these studies did not include short-term or long-term followup for exception, see Coles et al. Moreover, future studies with larger sample sizes that examine whether certain factors moderate treatment response e.
Having consistent and motivated caregivers and professionals who can advocate effectively for these children seems likely to contribute to more positive long-term outcomes. For example, in a study of high-school students with FASD, Duquette and colleagues proposed that persistence on the part of parents and caregivers played an important role in the social and academic outcomes of these students. People with FASD show deficits across multiple domains of adaptive functioning, including communication, socialization, and personal and community skills, and such impairments often are more severe than what would be predicted by their cognitive abilities Jirikowic et al.
In a recent study, 5- to 8-year-old children with FASD were compared with a group of typically developing children on a parent-completed scale of independent behavior Jirikowic et al. Almost half of the children with FASD required the most intensive levels of support from caregivers, whereas none of the children in the typically developing group required similar levels of support. The demand for such high levels of supervision likely places considerable stress on parents and caregivers. Children with FASD demonstrate marked deficits in their social functioning, including difficulties understanding social cues, processing social information, and communicating in social contexts McGee et al.
Such impairments represent an important target for intervention for this population, because poor peer relationships are predictive of early withdrawal from school and delinquency, as well as development of anxious and depressive symptoms Paetsch and Bertrand ; Patterson, et al. CFT is a group-based intervention that teaches social skills to help children be accepted by others rather than rejected, and includes instruction in parent-assisted peer network formation and informational exchange with peers leading to common-ground activities, peer entry, and play skills.
Children learn these skills through didactic instruction on the basic rules of social behavior, modeling, rehearsal, and coached practice with performance feedback during treatment sessions. To promote maintenance and generalization of the newly learned skills, in-session instruction is augmented with parent-assisted activities outside of the sessions, including rehearsal of skills at home, homework assignments e.
In a randomized controlled efficacy study, children with a history of moderate to heavy prenatal alcohol exposure were recruited from outpatient hospital clinics, community health care providers, and schools.
Behavioral Interventions for Children and Adolescents With Fetal Alcohol Spectrum Disorders
To be eligible for the study, participants had to be between 6 and 12 years of age, have a verbal IQ of at least 70 so that they would be able to comprehend the didactic component of the intervention, and have one parent or care-giver who could consistently attend the training. A total of 96 children and their parents completed the baseline and posttreatment phases of the study.
Compared with children in the DTC group, those who received CFT showed significantly greater improvement in their knowledge of appropriate social behavior and were rated by their parents as having better social skills and fewer behavior problems after treatment on the Social Skills Rating System SSRS Gresham and Elliott , a standardized parent-report measure. Moreover, these treatment gains were maintained at a 3-month follow-up assessment. Results indicated that at both posttreatment and the 3-month followup, mean scores for the CFT group moved from the clinical range to within the normative range but still remained significantly different from the normative sample mean.
Given the significant neurocognitive impairments that characterize many children with FASD, it is not surprising that there may be some limits to the treatment gains that can be yielded by a psychosocial intervention. However, although it may not be possible to completely normalize the social behavior of these children, the finding that their social functioning had moved to the normative range post-treatment and remained there at followup suggests that this type of intervention can have a significant clinical impact.
The CFT parent groups were conducted in both English and Spanish to accommodate the high percentage of Spanish-speaking parents in this community setting.
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A total of 85 families were enrolled in the study, and 67 families completed treatment. Completers and noncompleters did not differ on either important demographic characteristics or prenatal exposure. Preliminary analyses indicated that children in the CFT group demonstrated significantly greater gains in their knowledge of appropriate social behavior than children in the SOC group.
Similarly, parents of children in the CFT group rated their children as showing greater improvement in social skills than parents of children in the SOC group. Therapist satisfaction with CFT also was high, with 92 percent of the therapists who were trained to deliver CFT stating that they would like to see the intervention permanently adopted in their center. Findings from this effectiveness study are encouraging as they demonstrate that a research-based intervention to address social impairments in children with FASD could be successfully translated into a community setting and that these children can be treated in groups that include children with other kinds of behavioral, emotional, and social difficulties.
In general, children with disabilities and behavioral problems are at an elevated risk for unintentional injuries Sherrard et al. With this in mind, Coles and colleagues designed a computer-based intervention designed to improve fire- and street-safety skills in children with FASD Coles et al. Children were divided into one of two groups, and each group was taught appropriate rules and behavioral sequences in response to either one of two situations: a fire in their home, or crossing a city street.
Children were guided through the computerized training by an animated figure that presented information on fire safety or street safety in small, incremental steps.
Fetal Alcohol Spectrum Disorder | Health Care and Disease Management
Children were reinforced for correct actions and received feedback if they engaged in dangerous actions and then were taken back to the beginning of the behavioral sequence until they responded correctly. For more complex behaviors, children were not allowed to perform the sequence incorrectly, to prevent them from learning unsafe behaviors that might be more challenging to extinguish.
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Children in each intervention group fire safety or street safety demonstrated significant gains from pretest to posttest and from pretest to followup in safety-related knowledge and appropriate behavioral responses and significantly greater gains in comparison to the control group. Findings from this study suggest that it may be possible to apply computer-based interventions to the teaching of other safety-related skills, such as water safety or stranger awareness, to children with FASD. The studies described in this review attest to the notable progress that has been made in recent years in developing and testing interventions designed to remediate impairments in multiple domains of functioning among people with FASD.
Such studies offer some promise for families affected by FASD who often have considerable difficulty accessing appropriate services. Indeed, the results yielded by these studies begin to lay the foundation for a number of potentially fruitful avenues of investigation that will further expand the capacity of both clinicians and researchers to respond to the treatment needs of this vastly underserved population.