© FASCETS, Inc. PPC Teleconference January 27, 2015 Fetal Alcohol / Neurobehavioral Conditions: FA/NB Trying Differently Rather than Harder Understanding and Application of a Brain-based Approach Diane V. Malbin, MSW

© FASCETS, Inc. Neurobehavioral Foundation What if brain function has something to do with behaviors? It’s just a question… What’s the brain got to do with it?

© FASCETS, Inc.

Logic model: Is FA/NB a physical condition? 1.Alcohol, drugs, other teratogens and trauma kill cells and cause physical changes in the brain 2.Physical changes affect the structure and function of the brain 3.Behaviors are usually the only symptoms 4.FA/NB is an invisible physical disability with behavioral symptoms

© FASCETS, Inc. Conceptual framework: If FA/NB is an invisible physical disability Then Providing accommodations for people with FA/NB is as appropriate and effective as providing accommodations for people with other physical disabilities

© FASCETS, Inc. Examples of success Artist, musician Lecturer on FASD Electrician Boat builder Mechanic Child care worker Animal rescue worker Drummer, dancer BA, MA, MSW, PhD Office worker Special ed. teacher Counselor Massage therapist Truck driver Husband, wife Delivery person Parent Adult care worker

© FASCETS, Inc. Examples of birth parents Teacher Physician Therapist Office worker PhD Attorney Famous peoples’ children Administrator Friend Neighbor Supervisor Supervisee Relative Spouse

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Paternal Use: Findings of effects on pregnancy outcome 1.Low birth weight 2.Impaired cognitive skills, increased hyperactivity in sons of alcoholic fathers 3.Changes in behaviors of sons of alcoholic fathers 4.Low count and altered structure of sperm 5.Lower rates of pregnancies; sons were less fertile 6.Decreased activity of sperm and lower testosterone levels 7.Effects on epigenetics, or expression of genes on cognitive functioning

© FASCETS, Inc. Comparison: Effects of drugs on prenatal development Effects:AlcoholCocaineMarijuana Low birth weight X X Intellect, Development X Organ damage X Hyperactivity X X Source: US Department of Health and Human Services X

© FASCETS, Inc. Keith L. Moore

© FASCETS, Inc. Myelin sheath Dendrites Nuclei Axons Processes quickly Many interconnections Demyelination, processes slowly Fewer interconnections

© FASCETS, Inc. Neurobehavioral screening tool

© FASCETS, Inc. Definition: Primary characteristics Behavioral symptoms associated with differences in brain structure and function Strengths are also primary characteristics Source: Ann Streissguth, 1996

© FASCETS, Inc. Primary characteristics 1. Developmental level of functioning 2. Sensory systems 3. Nutrition 4. Language and communication 5. Processing pace: How fast the brain works 6. Learning and memory 7. Abstract thinking 8. Executive functioning 9. Strengths

© FASCETS, Inc. Uneven development 6-year-old Actual age of person:____ 6 Developmental age---3 Strengths (art, sports) Expressive language Receptive language-2 Reading Comprehension ----3

© FASCETS, Inc. Uneven development adolescent Actual age of person: 18 Developmental age Strengths (art, sports) Expressive language Receptive language----8 Reading Comprehension

© FASCETS, Inc. Learning strengths Relational: 1:1 Visual Auditory Hands-on Kinesthetic -- see, touch, move Experiential -- learns by doing Multimodal -- uses all senses

© FASCETS, Inc. Definition: Secondary characteristics Secondary defensive behaviors develop over time when there is a “poor fit” Defensive behaviors are normal reactions to pain and are preventable Adapted from : Ann Streissguth, 1996

© FASCETS, Inc. Anonymous, with permission

© FASCETS, Inc. Secondary behavioral symptoms Easily tired, fatigued Anxious Lonely, isolated Shut down; flat affect Fearful, withdrawn Depressed Frustrated, short fuse, angry

© FASCETS, Inc. Are the net result of a chronic poor fit, failure, isolation and alienation: As an extension of secondary behaviors, these are also preventable. Trouble in school Social services involvement Involvement with justice Homelessness Addictions/ mental health issues, suicide Tertiary symptoms

© FASCETS, Inc. Accumulation of DSM diagnoses: Short list Primary characteristics Attention Deficit Disorder Intellectual Disability (Intellectual Dev. Disorder ICD 11) Language Disorder Autism Spectrum Disorder Secondary characteristics Reactive Attachment Disorder Oppositional Defiant Disorder Post-traumatic Stress Disorder / Trauma Generalized Anxiety Disorder Personality Disorder

© FASCETS, Inc. Following diagnosis, then what? What is seen as the problem? What do we do to try to change behaviors? Note: Sometimes a person has FA/NB and other diagnoses. Brain function trumps behaviors. Start there.

© FASCETS, Inc. Fit between technique and ability Strategy example: Talking Assumptions about Brain function: Store information………………. Retrieve information…………… Form associations……………… Abstract…………………………. Generalize………………………. Predict…………………………… Conceptualize………………….. Process quickly…………………. Research on FA/NB has Found brain differences: Difficulty with memory Difficulty retrieving information Difficulty forming links Concrete Difficulty generalizing Difficulty predicting Gets piece, not picture Processes slowly

© FASCETS, Inc. Behavioral techniques based on learning theory are used in all systems: Parenting Education Justice Mental health Addictions treatment Social services Others

© FASCETS, Inc. What if? What if behaviors are symptoms of brain function? Would strategies to help a child see work for a child who is blind? What is more appropriate and effective?

© FASCETS, Inc. Between sessions activities Next month’s teleconference will focus on shifting thinking and developing strategies. It will be based on observations

© FASCETS, Inc. The importance of observation To observe without interpreting or assigning meaning To factor in brain function To move from crises to identifying patterns To depersonalize behaviors To clarify points of intervention and problem prevention

© FASCETS, Inc. Interpret or Observe? Nice Inappropriate Mean, did it on purpose On purpose Doesn’t care Based on what behavior? Describe action! Exactly what happened? How do you know? Describe affect. Flat? The goal is to observe without assigning values- laden meaning to the person or situation

© FASCETS, Inc. Observation log 1.Complete screening tool 2.Note if behaviors are primary or secondary 3.Observe what happened 1.Who, what, where when? 2.Were there any unexpected changes? 4.Note personal feelings 5.Accommodation?

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment A systematic approach to developing person-specific accommodations in all settings and managing the complexity of FA/NB

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting:____________________ Age: ___ Developmental age: ___ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learn

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast Slow processing pace

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast Slow processing pace 3

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast Slow processing pace 3Frustration

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast Slow processing pace 3FrustrationVisual learner

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast Slow processing pace 3FrustrationVisual learner Provide visual cues, use fewer words

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast Slow processing pace 3FrustrationVisual learner Provide visual cues, use fewer words Be age- appropriate Develop “on time” Dysmaturity 3Isolation depression Willing, relational Adjust expectations: “stretch toddler”

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: ___School___________ Age: _6_ Developmental age: _3_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Listen, learnProcess fast Slow processing pace 3FrustrationVisual learner Provide visual cues, use fewer words Be age- appropriate Develop “on time” Dysmaturity 3Isolation Depression Willing, relational Adjust expectations, “Stretch toddler” Sit and learn, paper and pencil Ability to abstract Concrete, difficulty with abstraction 2Anger, frustration, avoidance Learns by doing Hands-on Kinesthetic

© FASCETS, Inc. Application: Functional Neurobehavioral Assessment Setting: __Mental Health__ Age: _32_ Developmental age: _15_ 1 Task or Expectation 2 Brain has to 3 Primary symptoms FA/NB 4 Devel. Age (estimate) 5 Secondary behaviors 5 Strengths 6 Accommodations Cognitive behavioral techniques Abstract, analyze Concrete, literal 14May not finish assignments Artistic, experiential Art, drama, music, relationship, role modeling CommunicateProcess language Slow processing pace 12Anger, frustration Determined creative Art, drama, music, poetry Apply new knowledge Store, retrieve and generalize Memory problems, difficulty generalizing 16DefensiveRelationalTeach in different settings, use mentor

© FASCETS, Inc. Brain = behaviors Brain changes = behavioral changes

© FASCETS, Inc. Poor fit FA/NB Characteristic Visual learner……… Processes slower………. Needs external support.. Difficulty organizing……. Concrete…………… Strategy / expectation Verbal instruction Fast paced Work independently Organize, prioritize Abstract

© FASCETS, Inc. Good fit: Accommodations FA/NB Characteristic Visual learner……… Processes slower………. Needs external support.. Difficulty organizing……. Concrete…………… Strategy Provide visual cues Allow adequate time Provide supports Provide structure Teach experientially, build on strengths

© FASCETS, Inc. General starter strategies Stop fighting Ask: What if? Think younger Give time Recognize strengths Breathe Be kind to yourself

© FASCETS, Inc. Review 1.FA/NB is a brain-based physical disability 2.Reframe behaviors: Neurobehavioral Screen -- primary, secondary and tertiary symptoms 3.Application: Observation. Fit and accommodations Functional neurobehavioral assessment

© FASCETS, Inc. Diane V. Malbin, M.S.W. FASCETS PO Box Portland, OR