1. 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

2. 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

3. 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.

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

5. 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

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

8. 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

9. 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

10. 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

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

12. 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.

13. Cognitive Control Therapy

14. 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:

15. 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

16. Wilma Roussouw Conducting Cognitive Control Therapy – Field Articulation Task

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

18. 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 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 commenced interventions
October 2005 completed 9 months classroom interventions
Mid-December 2005 completed mid-intervention testing

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

21. 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.

22. 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)

23. 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.

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

25. 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.

26. 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

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

28. Pre-Intervention Language (PAELT) Analysis
% correct

29. Mid-Intervention Language (PAELT) Analysis
% correct

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

31. 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)

32. 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

33. 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.

34. 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.