Early intervention after an unfair start in life: Fetal exposure to alcohol
Those of us who work with people who have lived through adverse childhood experiences are familiar with the importance of individualizing treatment. We can do a lot of harm if we don’t consider what someone went through in life, or if we assume that one child’s preferences and needs are similar to those of another person.
Of course, this series about trauma has emphasized that it is the responsibility of ANY behavior analyst to individualize treatment, to consider the history of a client before moving forward with treatment, and to treat more than the “local” functions of behavior. Unfortunately, it is easy to miss the importance of this component of assessment and treatment, especially for new behavior analysts who have gained their “hours” working with highly similar clients, working without supervisors experienced in a diverse clientele, of without any supervisor or instructor who appreciates experimental as well as applied behavior analysis. One of the ways we find out more, is to go to the literature. This may be easier said than done, and an example of successfully data mining for this topic is provided toward the end of the article.
Today’s discussion involves clients who have been affected by what’s known as “Fetal alcohol syndrome”, or exposure to alcohol in the womb.
This is more than adverse childhood experience, for it goes back further in development, perhaps even as early as the neural tube (which will give rise to the spinal cord) and other important structures were being formed. This kind of exposure can affect an individual for their entire lifetime.
So we can consider it an adverse experience, although it happened even earlier than what we think of as “childhood”, and it has long lasting consequences, altering the way someone will learn and interact for the rest of their life.
Can we treat behavior after this condition?
And, for behavior analysts, how do we find research and literature on this topic? What can we say to people whose children and clients are affected in this way?
Any behavior analyst interested in this area is encouraged to do several things.
- Look at this like any other historical variable. Include related documentation in the FBA or functional behavior assessment. If we treated a person with autism as a person who learns in a “typically developing way”, and never mentioned to the team that we are treating behaviors in the context of an autism spectrum disorder, we might miss some of the characteristics that make it important to work on specific skills. Just as an adolescent with autism would likely benefit from specific support to gain social skills, a person who has been affected by FAS will need specific interventions related to “attention”, “social skills and relationships” and may have learning history that seems different than other people.
- Treat the behavior in the context of the whole person. Just as a person with autism might also have a physical disability or not, might have come from an abusive or supportive household, and might have been exposed to supportive educational practices or ineffective ones, a person with FAS has a full complement of other important historical variables, skills, physical and family characteristics, and so on. Just as a person with autism might have the challenges that range from severe or mild, a person on the fetal alcohol spectrum might not have great impairments of social interaction that are seen in another person with more severe symptoms and mental retardation.
- Use heavily individualized treatment, be realistic about progress, educate the team, listen to caregivers—and know that everyone can make progress. Understand that the trajectory of progress may not be the same as that of the next person. I have worked with several children (and older people) who were exposed to alcohol in utero. Every one made progress during therapy (early or later intervention based on behavior analytic principles), but there were differences between their programs and the others I wrote for people who did NOT come from this population. Here are some specific examples:
Difference 1: Attention is compromised (evident even in first months of life). People with fetal alchohol exposure do not show “attention” in the same way as others. From an extremely early age, they might seem to have struggles that look like they have an “attention deficit”, with their eyes and bodies moving quickly to different stimuli all the time. One of the early interventionists with whom I worked on a two year old’s case commented “I am trying to follow the child’s lead, but she keeps losing interest in items rapidly (after a few seconds). Should I keep following her lead, or do something different?” Yes, we needed to do something different. We wrote a program where we gradually built up staying with a toy or song from a second or two to almost a minute, but it progressed more slowly than similar programs with other children. We used structure very carefully.
Difference 2: Second, there is typically an impairment in social interaction and relationships that may persist as a person ages. Evidence* suggests that this may not be just a delay but a persistent difference, which may become more pronounced as a person grows older. However, a difficulty in a skill does not mean the person lacks motivation to use the skill. Again, if we always “followed the child’s lead” we might interpret their behavior as not wanting to interact with others, while they can greatly benefit from early and prolonged intervention to support them to learn and use more complex social skills as they get older.
Difference 3: Third, there are a host of general and specific learning impairments and behavior challenges that can be confusing for caregivers and educators to navigate. Considering that people with fetal alcohol exposure and related syndromes are already pre-exposed to variables that give them physical, medical and social interaction challenges, these can combine in dangerous ways that require skilled intervention and risk management. Physical and medical contributions to behavior may be some of the most often missed functions in the behavior assessments I observe young behavior analysts doing immediately out of school or with a supervisor who has not seen these documented before. But this does not suggest that evidence based treatment of the functions of challenging behavior cannot take place! In my work it is important to appreciate both the historical and local environmental contributions to behavior, and to educate caregivers to provide preventative supports.
*See references below article for more information on the deficits in attention, learning and social interaction in populations with FASD.
4. Expand your literature search: Where is behavioral treatment of FAS?
Since there is limited research published specifically on fetal alcohol spectrum disorders in behavior analytic journals, behavior analysts can do due diligence by expanding our search to include other journals using behavioral methodology that we can adapt or at the least, find informative. For example, in their review article on treatment approaches for individuals with fetal alcohol spectrum disorders, Paley and O’Connor (2009) cite several articles sharing supportive environmental strategies (breaking down complex tasks into simple steps, providing multiple daily behavioral rehearsal opportunities, and scheduling routines and predictable tasks. These are similar to the strategies this therapist (Kolu) uses effectively with clients affected by this spectrum, and can be delivered from a behavioral perspective. Additionally, when students with FASD show educational-specific area deficits related to challenges with learning (such an area of deficiency specific to math, caregiver interventions can support families to teach and practice math skills at home, producing gains that persisted over time (see Coles et al. 2009, referenced in Paley and O’Connor (2009); this was not published in a behavior analysis publication but is relevant to the specific support from which educators and caregivers and their students can benefit). O’Connor et al. (2006) found fewer behavior challenges after delivery of their manualized social skills intervention for families, including instruction and modeling, behavioral feedback and rehearsal, and parent coaching. Given the medical and biological variables underlying these disorders, this population carries significant risks to manage and document, such as the greater risk for medical problems (e.g., Church et al. 1997) and a high rate of sexually inappropriate behaviors (Streissguth et al. 2004). Despite these and other studies, there is still very limited evidence for effective interventions (e.g., Premji et al. 2006). Behavior analysts are reminded to take on the population only after appropriate study, experience and/or supervision (Code 1.02 a and b; 2.01a). If not, arrange for consultations and referrals (Code item 2.03a). When treating, we must insure the assessment is appropriate to the population (3.01a) and obtain medical consultation (3.02) if the behavior is informed by medical or biological variables.
5. If at first you don’t find it… mine the data
Example of mining the behavior analytic literature for FAS
Iwata et al. (1994) published the outcomes of 152 single subject functional analyses of self injurious behavior including 2 subjects with fetal alcohol syndrome, but unfortunately the data presented do not share outcomes for the specific subjects and genetic histories. Similarly, Mueller et al. (2011) mentioned FAS in the subjects characteristics table for one of the 69 students for whom functional analyses in school settings, but did not report outcomes for specific students. Finally, Borrero et al. (2007) published data from an impulsivity study which included one participant with FAS. Importantly, Borrero not only shared the outcome of the functional analysis (e.g., tangible), but also listed a cross referenced study (Vollmer et al.,1999) which went into significantly more detail about the conditions under which the child with FAS and the behaviors targeted and treated in one of the original studies. However, Todd’s diagnosis of FAS was never listed in the 1999 paper and is found only by cross referencing multiple studies in which the participant’s data were used. Of most significance, functional communication training was successful for the client with FAS who used severe aggression in the presence of food with his elderly grandmother/caregiver—but the results of the FA were undifferentiated until about sessions 20-30 (e.g., shown in data published in Vollmer et al. 1999). Because the study went on to examine impulsivity, we can see that unsignalled delay to reinforcement were still more likely to be followed by aggression than communication, even after communication training.
Each person can learn, and behavior relates to its environment. The environment in which a baby’s brain develops is an important “environmental variable” long before birth. Local function of behavior is important, but the role of biological factors (that make certain kinds of learning more or less difficult), is important too. This article was an example of looking beyond an abstract/keyword approach to discovering important contributions to the literature for a topic that is relevant to the population of clients a behavior analyst is tasked to treat. In fetal alcohol spectrum disorders, perhaps behavior worsens after unplanned “triggers” or unannounced changes or delays, making transitions more difficult the less structured the environment is. And behavior is affected by the brain, but also by experience: behavior is likely to be even more complex and challenging if a person with FASD is also exposed to subsequent abuse and/or neglect. If you or someone you know has more information you’d like to share with the BCBA-D composing this article, please share or let us know where we can find more.
Behavior Analysis Certification Board (March 21, 2016). Professional and Ethical Compliance Code for Behavior Analysts. Retrieved from https://bacb.com/wp-content/uploads/170706-compliance-code-english.pdf
Borrero et al. (2007). A unit price evaluation of severe problem behaviors. Journal of Applied Behavior Analysis, 40, 463-474.
Iwata et al. (1994). The functions of self injurious behavior: An experimental-epidemiological analysis. Journal of Applied Behavior Analysis, 27, 215-240.
Mueller et al. (2011). Functional analysis in public schools: A summary of 90 functional analyses. Journal of Applied Behavior Analysis, 44, 807-818.
Church, Eldis, Blakley et al. (1997). Hearing, language, speech, vestibular, and dentofacial disorders in fetal alcohol syndrome. Alcoholism: Clinical and Experimental Research, 21, 227-237.
O’Connor, Frankel, Paley et al. (2006). A controlled social skills training for children with fetal alcohol spectrum disorders. Journal of Consulting and Clinical Psychology, 74, 639-648.
Paley and O’Connor (2009). Intervention for individuals with fetal alcohol spectrum disorders: Treatment approaches and case management. Developmental Disability Research Reviews, 15, 258-267.
Premji, Benzies, Serrett and Hayden (2006). Research based interventions for children and youth with a Fetal Alcohol Spectrum Disorder: Revealing the gap. Childcare health and development, 389-397.
Streissguth, Bookstein, Barr et al. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Journal of Developmental and Behavioral Pediatrics 25, 228-238.
Thomas et al. (1998). Comparison of social abilities of children with fetal alcohol syndrome to those of children with similar IQ scores and normal controls. Alcoholism: Clinical and Experimental Research, 22, 528-533.
Vollmer et al. (1999). Evaluating self-control and impulsivity in children with severe behavior disorders. Journal of Applied Behavior Analysis, 32, 451-466.