The Midpoint Update - Three Educational Interventions for FASD Philip A. May, Ph.D. Colleen M. Adnams, M.D. Wendy O. Kalberg, M.A., CED Additional people to acknowledge: Bernice Castle Sean September Loretta Hendricks Marichen Perold Pharyn Sorour Anne Kotze Wilma Rossouw Petra Engelbrecht

Progress Report February 2006 Pilot Multi-method Intervention Study in Children in South Africa who are Alcohol Exposed Acknowledgements: NIAAA funding: RO1 AA 09440, RO1 AA 1685, UO1 AA014786

Specific Aims To determine the nature and degree to which 3 interventions improve academic skills and behavior in alcohol-exposed children. To assess the effects of three mediating variables (self-efficacy, attention, meta-cognitive skills) and three moderating variables (child’s IQ, life stress, maternal education) on therapeutic outcomes.

Three Methods of Intervention 1) Cognitive Control Therapy (CCT) 2) Language and Literacy (LLT) 3) Parent Intervention

Research Team Philip May (Principal Investigator); Wendy Kalberg, PW Kodituwakku (Co-Principal Investigators) The University of New Mexico Colleen Adnams (Co-Principal Investigator), Bernice Castle, Sean September, School of Child and Adolescent Health, University of Cape Town Petra Engelbrecht, Mariechen Perold, Department of Educational Psychology and Specialised Education, University of Stellenbosch Pharyn Sorour, Division of Communication Sciences and Disorders, University of Cape Town Rubin Adams, Western Cape Department of Education

Intervention Personnel Ellick Williams, Ed. Psych. Anna Kotze, Sp. and L. Therapist Wilma Rossouw, Ed. Psych

Methods 104 Children with FASD or normal controls were identified 81 children with FASD (FAS & PFAS) and 23 normal controls were randomized to 4 groups CCT LLT Parent Intervention FASD Control * 3 children lost to the study

Intervention Procedure Language Literacy – 2X week for 30 minutes each session Cognitive Control Therapy – 1X week for 60 minute sessions Parent Group – significant attrition due to overwhelming life circumstances

Participant Evaluation Baseline testing prior to intervention Two reading measures A spelling test Two mathematics tests Two language tests Cognitive Control Battery Visual Acuity Auditory Screening Behavior and self-efficacy measures through parent and teacher questionnaires

Language Literacy Intervention Audiology evaluation Sound production Semantics (word meanings) Language syntax Phonological awareness Letter knowledge Rapid automatic naming tasks (automatic processing)

Parent Intervention Parent concerns regarding real-life scenarios Discuss parent’s role in educating their child Attrition in parent groups great, discontinued the groups in fall, 2005.

Cognitive Control Therapy

Cognitive Control Therapy Based on information processing paradigm of cognition/intelligence Receive information – linked to sensory system, perceptual skills, and nervous system integrity Process information – utilizing executive controls Knowledge Schemes Control Processes Metacognition - Campione, Brown, and Borkoski, 1985 From Jean Esquirol 1838 who made the distinction between mental deficiency and mental illness to Howard Gardner who posited Multiple Intelligences theory, many theorists have tried to define cognition/intelligence Information Processing Models provide one paradigm Receiving Information information is received and then passed on to a higher order mental operations for processing Reception of the information in the first place, though, is dependent on attention, memory span, retention, speed of encoding and decoding as well as perceptual skills and general nervous system integrity. Processing the Information Executive system takes over for the processing utilizing environmentally learned factors that guide problem solving knowledge base schemes control processes metacognition These interdependent factors include existing knowledge, attention, planning, retrieval of information from long term memory, working memory, assimilating or accommodating new information, and then using strategies such as self-checking and rehearsal to achieve greater generalization of the information Finally, metacognitive processes involving one’s own awareness of thought processes and strategies and how certain cognitive strategies help you or hinder the ability to take in new information. e.g. I know that my memory for names is poor and that I must impart a memory strategy when being introduced to new people. That strategy involves saying the person’s name immediately or shortly after having been introduced to try to input the name into my memory. Another strategy I use is to say the work repetitively to myself to make sure it is set in my memory. Cognitive Control Therapy Works off of these tenants……that we can positively influence an individuals ability to process information through intervention techniques focused on the following heirarchical cognitive controls:

Santostefano’s Controls Body ego-tempo regulation Focal attention Field articulation Leveling-sharpening Equivalence Range * Sebastiano Santostefano, Ph.D., 1989 Body ego tempo – manner in which an individual mentally regulates his body and body movements Focal Attention – manner in which individual scans a field of information Leveling and Sharpening – manner in which an individual compares images of past information with percetpions of present information Equivalence Range – manner in which an individual categorized and conceptualized information Field Articulation – manner in which an individual attends selectively to a particular stimulus while ignoring others

Wilma Roussouw Conducting Cognitive Control Therapy – Field Articulation Task

“Where’s Waldo” as Part of Field Articulation Control Segment of CCT

Accomplishments 2003 – March 2004: planning, development of core and specific test batteries SA + UNM co-researchers March /May 2004 – recruitment and training psychometrist. Translation of tests, questionnaires May, June 2004 - participant recruitment via field worker visits to parents → 98%. June 2004 – commencement of baseline testing, interviews, questionnaires. Recruitment of co-ordinator. August 2004 – randomisation of FASD participants to intervention groups; preparation for interventions September 2004 - commenced interventions October 2005 completed 9 months classroom interventions Mid-December 2005 completed mid-intervention testing

All Baseline Measures Significantly Different between FAS and Controls Behavior-FASD children less self-regulated Math Spelling Reading Syllable – identification and segmentation

Lessons Learned – Parent Group Parents overwhelmed by poverty and adverse social and environmental circumstances are unlikely to sustain attendance or participation in group intervention programmes aimed at parenting skills, in spite of significant practical support and positive feedback by the participants. This intervention was withdrawn due to significant parent attrition. Follow up interviews are in progress.

Mid-Intervention Testing After 9 – 10 months of intervention All of the baseline measures were repeated for the children enrolled in the study (testing completed by Dec. 16, 2005)

Mid-Intervention Data Assessment with the core cognitive battery, language assessment and the Cognitive Control Battery was undertaken after 9-10 months of intervention Mean age of participants = 125 mths (10.5yr) The 5 groups (2 control, 3 intervention) were analysed separately. 3 children lost to the study. The intervention and control groups all showed improvement in maths, spelling, reading and comprehension compared to the pre-intervention assessment.

Mid-Intervention Achenbach Results show significant differences in all DSM-IV domains, between children with FASD attending interventions and those who do not.

Results at Mid-Intervention: General and Cognitive Significant differences between FASD children and non-exposed controls persisted in reading*, spelling*, addition*, subtraction*, number problems*, reading comprehension* and self-efficacy* (*p<.001). There were no significant gains by the classroom intervention groups over the FASD controls on core cognitive assessments, Cognitive control Battery or Self Efficacy Behavior Scales. Qualitative improvements in self-regulation and attention were observed by the therapists.

Mid-Intervention: Literacy Phonological Awareness and Early Literacy Tests (PAELT) were administered to the Literacy Group (n=18) FASD controls (n=20) and non-exposed controls (n=23). This battery assesses pre-literacy functions: sound awareness and discrimination (word completion) discrimination of syllable segments of words auditory analysis and synthesis

Results: Literacy The Pre and mid-intervention scores as well as percentage improvements for the Language intervention, FASD and non-exposed groups were compared.

Pre-Intervention Language (PAELT) Analysis % correct

Mid-Intervention Language (PAELT) Analysis % correct

Mid-Intervention: Language (% Improvement) (PAELT)

Results: Mid-Intervention by Domain In some cognitive areas, greater improvements occurred from pre- to mid-intervention in the classroom intervention groups than the other study groups In the Language/Literacy group, improvement in phonological working memory (mean digit span scale score gain= 1.13) was greater than in the FASD control and CCT groups (mean scale score FASD control = 0.15; CCT = 0.03)

Mean Percentage Pre- to Mid-intervention Improvement in Reading Comprehension: greater in the Lang/Literacy and CCT (classroom intervention) groups, especially the language group % improvement

Mid-Intervention: Conclusions Children with FASD show cognitive improvements in specific areas following classroom interventions. Classroom learning and behavior will be further re-assessed after another 9 months intervention.

The language and literacy intervention group at midpoint showed greater improvement in pre-literacy skills than the FASD control group. The normed reading test used may not have identified significant improvements occurring in children with FASD at lower levels of literacy or pre-literacy function than measured by the test. This may also be true for other normed tests on our battery.