Fetal Alcohol Spectrum Disorder (FASD) Interventions
The considerable variability in the type and extent of deficits of FASD has led to the development of efficacious interventions becoming a particular challenge. A diagnosis of FAS or the identification of an FASD does not lend itself to a single effective treatment practice that could target the entire range of neurobehavioral problems which an individual may have (Hannigan and Berman, 2000). The various combinations of physical, mental, behavioral, and learning/educational problems among individuals with PAE highlight the complexity of these disorders, and the necessity for interventions that are problem-specific as well as flexible.
Rather than confront the entire scope of the disorder – which may be overwhelming and unfeasible – specific behavioral problems should be identified in order to direct specific treatments (Hannigan and Berman, 2000). For example, recent research into interventions for FASD has demonstrated the efficacy of targeted treatments for social skills impairment associated with prenatal alcohol exposure (Paley and O ’ Connor, 2009).
In addition to intervening with alcohol-exposed individuals to mitigate the deficits and consequences of PAE, treatment practices should focus on providing education and support to the families and caregivers of these individuals. The consequences of FASD extend far beyond the experiences of affected individuals. Both biological and foster parents often experience high levels of stress associated with dealing with their child’s impairments (Paley et al., 2006). Many foster parents have expressed their need for more education about FASD, parenting skills training, social support, and professional services to help raise a child with alcohol- related disabilities (Brown, Sigvaldason, and Bednar, 2004).
In fact, it has been shown that educating parents and caregivers to realize that the origins of their child’s behavioral problems are rooted in brain changes may help them become more understanding and respond to their child in a more supportive manner (Paley and O’ Connor, 2009). Interventions should address the issues of the families of those affected by PAE in order to improve their own adjustment and functioning, as well as that of their child.
Current research supports the efficacy of numerous treatment approaches for individuals with FASD as well as their caregivers (as reviewed in Paley and O’ Connor, 2009). These treatments include educational and cognitive interventions, parenting interventions, and adaptive skills training. Children exposed to alcohol during pregnancy present with an array of neuropsychological deficits such as overall lower intelligence performance, impaired learning and memory and executive functioning, attention deficits, and hyperactivity. These impairments often result in educational difficulties, including inferior school performance (Mattson et al., 1998), learning disabilities (Burd et al., 2003), and classroom behavioral problems (Carmichael Olson et al., 1991).
What Type of Intervention Should Be Used?
Key factors influencing our choice of intervention for FASD included effectiveness, cultural appropriateness, ability to meet a community’s needs and characteristics, portability, and resources (e.g., training, personnel, people skills, equipment, and funding). In the end, we chose the “brief alcohol intervention” approach, which derives from motivational interviewing and cognitive behavioral therapy, and usually consists of one or more short counseling sessions that focus on changing behavior. In non-Aboriginal populations, the evidence indicates that brief alcohol interventions are effective, cost-effective, and versatile . Success in reducing heavy alcohol use has been shown across various targeted behaviors, different populations, various delivery methods, and delivery by different interveners. Brief alcohol interventions have also led to significant long-term reductions in alcohol consumption among women of childbearing age.
Typically, such interventions have five core characteristics: (1) identification of at-risk women, (2) assessment of drinking behaviors, (3) provision of information on the harmful effects of drinking, (4) method of delivery that facilitates decisions to adopt healthier drinking behaviors, and (5) monitoring of changes or progress . To facilitate the initial stages of intervention development at each site, the Fleming brief alcohol intervention model was used as an example . Although the Fleming model was designed to be an office-based “brief physician’s advice” approach, we believe it provided an excellent example to study and build on.
Would the Intervention Be More Effective in a Specific Target Population?
Initially, it was assumed that all women of childbearing age would constitute an appropriate target population for FASD prevention strategies. While this seemed self-evident, we had the opportunity of evaluating the possibility that the intervention might be more effective in a specific subgroup of these women. Women who had previously given birth were selected as the target population for the interventions, since evidence indicates that FASD is associated with increasing maternal age and parity. Thus, the optimal time to identify at-risk women and prevent fetal injury may be after the first pregnancy. The results from an Ontario Federation of Indian Friendship Centres study support this approach, showing that more women reported drinking during a second pregnancy than during the first.
Targeting postpartum women addresses three important issues. First, women who are at highest risk for alcohol use during pregnancy may be the least likely to seek medical care early in pregnancy. Mothers who are at risk for continued alcohol use can be identified through birth events such as postnatal checkups. Second, the intervention takes place prior to subsequent pregnancies, thereby preventing prenatal alcohol exposure. Third, women who have recently given birth may have heightened interest in maternal and child health, which may benefit subsequent pregnancies.
Educational interventions are focused on developing teaching strategies that facilitate learning in alcohol - exposed children, such as modifying classroom environments that may interfere with a child’s ability to learn, and providing support and resources for teachers to help them adapt their instruction and improve their ability to work with students with FASD (Paley and O’ Connor, 2009). Additionally, cognitive and academic interventions aim to help enhance skills that will improve an individual’s academic performance, focusing on improving general learning skills and/or specific cognitive or academic domains (Paley and O’ Connor, 2009). Some of these interventions include cognitive control therapy (CCT) (Riley et al., 2003), language and literacy training (LLT) (Adnams et al., 2007), rehearsal strategies to improve working memory (Loomes et al., 2008), and socio-cognitive habilitation programs to improve behavioral and math functioning (Kable, Coles, and Taddeo, 2007).
As mentioned above, raising children with FASD can be particularly challenging, since many parenting strategies that may be effective with typically developing children may not be successful with alcohol-exposed children. Parent-focused interventions should develop effective parenting skills, improve the parent – child relationship, decrease parent stress, and increase parental self-efficacy (Paley and O ’ Connor, 2009). Parent – child interaction therapy (PCIT) (Eyberg and Boggs, 1998), parenting support and management (PSM), and supportive behavioral consultation – particularly families moving forward (FMF) (Bertrand, 2009) – are evidence-based practices that provide parents with the necessary support and skills to manage the difficulties of raising a child with the consequences of PAE, and to improve their relationship with their child.
Finally, adaptive skills training helps individuals with FASD to develop important age-appropriate skills that help them become less dependent on others and function more independently in their everyday lives. Adaptive skills training may target a range of functional domains, including communication, social interactions (O’ Connor et al., 2006), and safety skills (Coles et al., 2007). Clearly, a multi-faceted approach to the prevention and treatment of FAS/FASD, targeting at-risk and affected individuals as well as their families/caregivers, is important in order to mitigate the detrimental personal and societal effects of PAE.
Acknowledgments
These studies were funded in part by grants R01 AA10417 and U24AA014811 to EPR from the National Institute on Alcohol Abuse and Alcohol, National Institutes of Health, USA.
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Tanya T. Nguyen, Jennifer Coppens, and Edward P. Riley
Edited by Edward P. Riley, Sterling Clarren, Joanne Weinberg, and Egon Jonsson
Tanya T Nguyen practices as a Pediatrician in Alhambra, CA.
Jennifer Coppens, Medical Student, University of Alberta
Prof. Dr. Edward P. Riley San Diego State University Center for Behavioral Teratology
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