IHS 2009 National Behavioral Health Conference August 6 ......The reason "they act the way they do" is Brain Damage Retrain your own brain to think in terms of Brain Damage Even when

FASD: A New Model for Achieving

Consistent and Creative Interventions that

Work 1

FASD: A New Model 1

The FASD Wheel™

A New Model for Achieving Consistent and Creative Interventions that Work

IHS 2009 National Behavioral Health Conference

August 6, 2009

Michael L. Harris, M.A., L.P.

Director, Counseling & Support Clinic

Indian Health Board of Minneapolis, Inc.

FASD: A New Model 2

IHB‘s Location:

FASD: A New Model 3

Disclaimer While some specific interventions and ideas for helping children with FASD will be offered, the workshop‗s primary emphasis will be about one's conceptualization of FASD

It is about Knowledge and Retraining Your Brain in how to think and problem-solve when confronted with FASD Brain Damage Behaviors

Metaphor and "cartoons" teach the concepts

FASD: A New Model 4

ActivityTake two minutes and jot down your answers to…

Why does the person with FASD that I know do what she does?

1. See the FASD Elephant™ -- Analyze FASD with a new Metaphor

FASD: A New Model 5

How Many Squares?

FASD: A New Model 6

Good Frog – Bad Frog

When is she a good frog?

When is she a bad frog?

(Stay till the end )…



Work 2

FASD: A New Model 7

Assumptions & Misattributions

• Assumption: Hypothesis, Guess,

Statement, Notion, Belief, Idea

• Attribution: Attributing a reason

to a behavior

• Misattribution: Logical but

incorrect reasoning about behavior

FASD: A New Model 8

Elephants

American poet John Godfrey Saxe (1816-1887) based his poem about six wise people who could not see on a fable that was told in India many years ago.

It is a great warning on how perceptions and beliefs (even when based on data) can lead to misinterpretations.

FASD: A New Model 9

The FASD Elephant™

FASD: A New Model 10

The Answer to the QuestionThe answer to almost every question about FASD is, "Brain Damage"

The reason "they act the way they do" is Brain Damage

Retrain your own brain to think in terms of Brain DamageEven when that little voice in your head says, "But I know he can do it—he can sit in front of a video game for hours!"

Assume 1st you're dealing with Brain Damage


Brain Overview

The many interacting parts of the brain (neurons, brain circuits, and brain structures) communicate and learn to allow humans to do, know, and feel everything.

2. Understand FASD Brain Damage – A Brief Overview of Brain Functioning


Brain Development: Neurons

The brain develops over time—elementary neurons begin forming by the 16th day after conception and grow by the thousands throughout gestation



Work 3


Brain Development: Synapses

Synapses: The trillions of tiny spaces between neurons' dendrites and axon terminals filled with cerebral fluid

Neurotransmitters: Chemicals produced by neurons to activate and communicate with each other.


Brain Development: Circuits

A brain circuit is a group of neurons in a pathway that communicates together on a regular basis for a particular purpose

New synapses formto facilitate andcreate new circuits(and learning)


Neurons grow and migrate, forming genetically programmed brain circuits and structures:

Cerebrum/Cortex–Perceptions, Processing, Thoughts, Actions, etc.

Cerebellum–Regulation of Movement

Limbic System–Emotions

Brain Stem–Vital Life Functions

Brain Development: Structures


Brain Development: Learning

Some brain circuits are hard-wired

Other brain circuits develop before or after birth

A new circuit can form from

Repeated experience, like routines and practicing

Intense experience, like pain or pleasure


Brain Development: Repetition

A "cartoon" example of learning from repeated experience: Memorization


Brain Development: Intensity

A "cartoon" example of learning from intense experience: A hot stove



Work 4


Brain Development: Summary

Memory, habits, and beliefs form from repeated or intense brain stimulation

Brain Stimulation

Grows more synapses

Strengthens brain circuits

Improves brain circuits' communication

At least, it does in a "normal" brain


Example: Acute Stress Response

The amygdala decides if what we see, hear, and/or feel is dangerous

The hypothalamus raises heart rate, blood pressure, and adrenaline

This is an acute stress response, also known as "The Fight or Flight Syndrome"


Example: Acute Stress Response

Reality check: The amygdala also signals our higher-level thinking centers


Example: Acute Stress ResponseDamaged FASD brain circuits cannot communicate properly or easily or consistently

Acute stress response might or might not trigger

Acute stress response might be enjoyed

The higher-level thinking centers of the brain may or may not be included in the analysis loop

Perseveration or "looping" might occur (freezing)

Pain (feedback) might not be felt as strongly

FASD brain circuits work together abnormally


FASD = Brain DamageExample of "normal brain" (left)

With "normal" brain circuits

Extreme example of FAS brain (right)

With garbled brain circuits


The 4 Key Features of FASD

1. Growth – Can see it, but doesn't matter

2. Face – Can see it, but doesn't matter

3. Central Nervous System Damage –Can't see it, but it does matter

4. Prenatal Alcohol Exposure – Can't see it, but does matter



Work 5


The Ten Brain DomainsBrain functions that produce outward behaviors can be grouped into ten measurable categories, or domains:

1. Achievement 2. Adaptive Behavior

3. Attention 4. Cognition

5. Exec. Functions 6. Language

7. Memory 8. Motor Skills

9. Sensory ("OT") 10. Social Comm.

*Assessing Central Nervous System (Brain) Damage


The Ten Brain Domains

Each Brain Domain is assessed by standardized testing and/or observation

Functioning level for each Brain Domain is ranked according this scale:

Within Normal Limits – Average functioning

Borderline – Mild problems

Moderate – Moderate problems

Significant/Clinical – Severe problems

*Assessing Central Nervous System (Brain) Damage


Brain SummaryAll behaviors are organized and controlled by the brain

A "normal" brain uses circuits in a "normal" fashion to produce normal, understandable, reasonable, predictable outward behaviors

A brain damaged and garbled by FASD can't process or use information "normally;" it produces unexpected and unusual behaviors


A Pause – BREAK

Questions or comments so far

Terror – Dissociation

Fear – Fight or Flight

Alarm – Freezing (Cats)

Vigilance – On the ―Look-Out‖

Calm – Normal Resting State


FASD Wheel™ Overview

The FASD Wheel™:

A visual cue or reminder of the strengths and weaknesses of each Brain Domain

Visually represents the difficulty of a person's "Ride Through Life"

Supports data-driven decisions for responding to an "FASD situation"

Helps avoid misattributions

3. Using the FASD Wheel™ Model – Practical Application


The FASD Wheel™

Divide a circle into 10 sections:

Each sectionrepresents aBrain Domain



Work 6


The FASD Wheel™Normal functioning in any brain domain is represented by coloring in its complete section of the FASD Wheel™.

Since prenatal alcohol exposure destroys parts of the brain, deficits and problems in brain domains have a portion missing:

Normal Limits = A full section

Borderline = 1 chunk out

Moderate = 2 chunks out

Significant/Clinical = 3 chunks out


The FASD Wheel™Normal functioning FASD functioning


The FASD Wheel™Just imagine what your "ride through life" would be like using this wheel!

We fill in the gaps with interventions,

And, build the environment up with accommodations.

FASD functioning


1. AchievementSkills that are taught in school as subjects of study, especially reading, math, and written language

Also depends on memory, attention, language, visual perception, and motor skills domains

What people say1:

Report cards are always bad

Can't do math

Simply not motivated

Doesn't learn from mistakes

1From JFAS Int., 2006 (4), 8-11. © The Hospital for Sick Children; FADP; ARC Northland; University of WA –FASDPN.


Assessing AchievementFormal Assessment:

Wechsler Intellectual

Achievement Scale-2 (WIAT-2)

Woodcock-Johnson

Achievement (WJ-3)

Wide Range Achievement

Test (WRAT-4)

Standardized school testing

Curriculum-based measures

California Achievement Test

MN graduation skills tests

Other school testing

Informal Assessment:Grades, report card

Homework

Classroom work

Teacher perception

Special education services for academic skills

School gets harder and harder with each grade

Doesn't pay attention in class


2. Behavioral AdaptationSkills for daily livingat home, school, or community

Personal hygiene

Safety skills

Appropriate leisure

Following expected societal rules

Social skills

Sexual behavior

What people say1:Needs to be the center of attention

Needs 24-hour supervision

No "stranger danger"

Doesn't consider brushing hair or teeth or bathing

Plays with younger kids

Acts younger than age

Pathological liar




Work 7


Assessing Adaptive BehaviorFormal Assessment:

Behavior Assessment Scale

for Children-2 (BASC-2)

Adaptive Behavior Assessment Scales (ABAS-2)

Vineland Adaptive Behavior Scale (VABS)

Classroom observation

Social skills evaluations

Informal Assessment:Plays more with younger kids

Poor social skills

Few friends, or new friends every week

Oppositional, defiant

Frequent lying

Frequent stealing

Odd, atypical behaviors

Can‘t handle free time

Inappropriate sexual behavior

Breaks just about every toy


3. AttentionAbility to maintain selective, sustained, focused attention

Had to be a problem before age 5

Can interfere with functioning in many domains

What people say1:Busy body

Just can't sit still

Cannot focus

"Spaces out" sometimes

Hyper all the time

Fidgets all the time



Assessing AttentionFormal Assessment:

Behavior Assessment Scale for Children-2 (BASC-2)

Conners' Rating Scales (CRS-2)

Conners' Continuous Performance Test (CPT-2)

Other continuous performance tests (e.g., TOVA)

NEPSY-2 (Psych Corp)

Other rating scales

Home, office, classroom observations

Informal Assessment:Cannot wait turn

Poor impulse control

Short attention span

Forgetfulness

Hyperactive most of the time

Disorganized

Can't settle for bedtime

Doesn't complete tasks or chores

Frequently moves from one thing or activity to the next


4. CognitionProblem-solving and thinking abilities

Verbal processing, information, and comprehension

Nonverbal processing or manipulation of concrete materials or visual stimuli

Short-term memory

Processing efficiency

What people say1:Not too bright

Dull

Simply not trying (or not trying hard enough)

Lazy

Slow learner

1From JFAS Int., 2006 (4), 8-11. © The Hospital for Sick Children; FADP, ARC Northland; University of WA –FASDPN.


Assessing CognitionFormal Assessment:

Wechsler Scales

WPPSI-3 (Preschool)

WISC-IV (School age)

WAIS-3 (Adults)

Woodcock-Johnson-

Cognitive (WJ-3)

Stanford-Binet

Other standardized IQ tests

IQ tests can be culturally

inappropriate, depending one‘s experience with the tasks and how the results

are interpreted

Informal Assessment:Grades, report card

Repeats grades in school

Limited skills

"Slow"

School gets harder and harder with each grade

Needs lots of help with problem-solving

Child has unrealistic goals

Doesn't understand money

Doesn't understand time


5. Executive FunctioningThe capacity for goal-directed behavior, including decision-making, self-regulation, self-direction, planning, predicting, inferring, deducing, working memory, and organizational skills

What people say1:Doesn't seem to learn from experience

Doesn't seem to know the difference between stealing, borrowed or found (but knows better)

So easy to tease, gullible

Simply doesn't get it

Can't see what's coming

Disorganized




Work 8


Assessing Executive FunctionsFormal Assessment:

Wisconsin Card Sorting Test

(WCST)

Porteus Mazes

NEPSY-2

BRIEF – Caregiver ratings

Trails test

Neuropsychological Evaluation

MRI

Informal Assessment:Big change in school performance at 3rd/4th grade

Doesn't understand irony, metaphor, sarcasm, figures of speech, riddles, and/or joking

Needs lots of concrete help with problem-solving

Doesn't accept responsibility

Little understanding of cause and effect

Problems with time and money

Poor judgment, poor memory


6. LanguageExpressive language

Communicating for others to understand

Receptive language

Understanding what others say to you

Ability to use skills of grammar, syntax, sentence structure

What people say1:

Child's statements do not

make sense or are "out

of the blue"

Not good at verbal problem-solving

Understands better with

pictures or being shown

how

Talks all the time

1From JFAS Int., 2006 (4), 8-11. © The Hospital for Sick

Children; FADP, ARC Northland; University of WA –

FASDPN.


Assessing LanguageFormal Assessment:

Clinical Evaluation of

Language Fundamentals (CELF-4)

BASC-2, ABAS-2, NEPSY-2

Formal speech-language evaluation

Other standardized language tests

Language tests must take

into account regional and cultural experiences based on one‘s experience and

background

Informal Assessment:Tells stories that make little

or no sense

Repeats or perseverates words, phrases, or ideas

Can't follow multi-step instructions

Can repeat back but not implement instructions

Poor vocabulary

Late onset talking

Has had speech therapy


7. MemoryThe capacity to take in, encode, store, & retrieve information

Short-term and long-term memory

Nonverbal memoryProcedural, skills

Verbal memoryMore factual, or information-based

What people say1:Every day is a new day

Loses or misplaces things a lot

Quick recovery from a crisis

Doesn't remember to do chores

Can't do more than one thing at a time




Assessing MemoryFormal Assessment:

Wechsler Memory Scales

(WMS-3)

NEPSY-2

WPPSI-3, WISC-IV, WAIS-3

(have a working memory index)

CELF-4 (language memory)

Other standardized memory

tests

Informal Assessment:Can't follow multi-step instructions

Can't remember rules to games, so makes up rules

Confabulation – Trouble remembering an answer, so just makes one up (but it sounds like lying)


Must relearn often

Trouble learning basic math facts or reading facts (which letters make which sounds)


8. Motor (Fine & Gross Skills)Capacity to use and coordinate small and large muscles

Fine MotorSmall muscles for manipulating objects, handwriting, etc.

Gross MotorLarge muscles for walking, throwing, etc.

What people say1:

Late walker

Took a long time to learn

how to ride a bike

Can't tie shoes

Very clumsy, or

uncoordinated

Has poor posture

Handwriting is sloppy


Children; FADP, ARC Northland; University of WA –

FASDPN.



Work 9


Assessing Motor SkillsFormal Assessment:

Beery Visual-Motor

Integration (VMI)

NEPSY-2

Bailey Scales of Infant

Development (BSID-2)

WPPSI-3, WISC-IV, WAIS-3

(have motor skills subtests)

Occupational Therapy

("OT") evaluation

Medical examinations

Informal Assessment:Poor swallowing or sucking

reflex as an infant

Late walker, or toe walker

Took longer than other kids

to learn buttoning buttons, tying shoes, using zippers,

riding a bicycle, etc.

Poor balance, clumsiness

Poor or sloppy penmanship

Hand tremors

Poor ability to throw a ball


9. Sensory/Soft NeurologicalSensory Integration

How information from the senses is processed by the brain; Poor SI means info is uncoordinated

Soft Neurological

Immature or weakened nervous system

What people say1:

Sensitive to loud noises

Hates tags on shirts and

other clothes

"Touchy-Feely"

Seems to need more

touch than other kids

Smells stuff all the time

Sleeps with lots of blankets

1From JFAS Int., 2006 (4), 8-11. © The Hospital for Sick Children; FADP, ARC Northland; University of WA –

FASDPN.


Assessing Sensory/Soft NeuroFormal Assessment:

Beery Developmental Test

of Visual-Motor Integration (VMI)

Bailey Scales of Infant

Development (BSID-2)

Occupational Therapy

("OT") evaluation

Medical examinations

Informal Assessment:Colicky as an infant

Self-rocking, bangs head, or

other self-stimulating or self-soothing behaviors

Avoids certain textures (e.g., dirt, sand, scratchy clothes)

Dislikes bright lights, strong odors, loud noises

Has a strong startle reflex

Only eats favorite foods

Easily over-stimulated


10. Social CommunicationCapacity to communicate appropriately and effectively in a variety of social situations, reading and using social cues with both peers and adults

Functional aspects

What people say1:

Bosses friends around

Doesn't have friends

Can't read body language

Blames others for

problems

Doesn't have empathy

Chatty all the time

Disrespectful to teachers


Children; FADP, ARC Northland; University of WA –FASDPN.


Assessing Social CommunicationFormal Assessment:

ABAS-2

VABS

BASC-2

Observations with peers and

authority figures

Informal Assessment:Practical application of

language skills

Difficulty relaying information to others

Difficulty coping with change in social situations (rigid)

Doesn't understand body language or personal space

Says inappropriate things for the situation

Uses "baby talk"


Mental Health ConfoundsFASD brains process and use information differently according to the presence of internal and external stressors—more stressors equal poorer processing, and therefore "worse" behaviors

Diagnoses:Mood Disorders

Major Depression

Dysthymic Disorder

Anger/Rage/Tantrums

Attachment problemsReactive Attachment

Self-Regulation problems

Anxiety DisordersPosttraumatic Stress Disorder (PTSD)



Work 10


A Pause

Questions or comments so far

Now, pulling it all together…


FASD Wheel™ Case Study

An FASD Evaluation Report reveals the following results for the Ten Domains:

Achievement Scores (WRAT-3)

Reading: 76

Mathematics: 94

Spelling: 79

Overall: 83

(You would find these scores in the report; usually they will have labels, too.)


FASD Wheel™ Case StudyRemember, each domain (and subdomain) can be scored and ranked:

Within Normal Limits – usually 90 or higher

Borderline (or Low Average) – 80 to 89

Low/Moderate – usually 70 to 79

Very Low/Clinical – usually less than 70

Achievement Scores (WRAT-3)Reading: 76 => Low

Mathematics: 94 => Average

Spelling: 79 => Low

Overall: 83 => Borderline


FASD Wheel™ Case StudySince the overall Achievement score is Borderline, remove at least one chunkfrom the Achievement section of the FASD Wheel.

Clinical experience may suggest using the lowest score, if school achievement is especially low in actual practice.

Also, we use the "worst score" with physical findings.




FASD Wheel™ Case StudyAdaptive behavior is usually rated by caregivers, teachers, & self (older kids):

Adaptive Behavior ScoresBASC (Parent) – Activities of Daily Living (BASC-2 ADLs are reverse scored) 34 (Borderline)

ABAS – Overall (Parent): 45 (Very Low)

ABAS – Overall (Teacher 1): 72 (Low)

ABAS – Overall (Teacher 2): 82 (Borderline)

Use the "worst" score; with this range, the difference is in the environment.



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FASD Wheel™ Case StudyAttention is usually rated by caregivers and teachers, and measured by continuous performance tests on a computer:

Attention Scores

BASC (Parent) – Attention: 84 (Clinical)

NEPSY (Attention/Exec. Function): 85 (Borderline)

Conners CPT: 0 (Normal Limits)

But, child was medicated during testing; ignore CPT in

this case (clinical judgment made here).

BASC scores are calculated differently, so just pay attention to the descriptor label—Clinical.




FASD Wheel™ Case StudyCognition is usually measured by an IQ test. Be sure cultural issues are considered:

Cognitive Scores

WISC-IV Verbal Comprehension: 95 (Average)

WISC-IV Perceptual Reasoning: 98 (Average)

WISC-IV Processing Speed: 89 (Low Average)

WISC-IV Full Scale IQ: 95 (Average)

Porteus Maze: 103 (Average)

The Porteus is less culturally biased, but it can be affected by familiarity with mazes. Use the "worst" score; again, it helps direct interventions.




FASD Wheel™ Case StudyExecutive Functioning can be tested by several means; we use Porteus and NEPSY:

Executive Functioning Scores

NEPSY Attention/Exec. Functioning:79 (Low)

NEPSY Memory & Learning: 71 (Low)

WISC-IV Processing Speed: 89 (Low Average)

Porteus Maze: 103 (Average)

The Executive Functioning ranking may be difficult to make by a layperson just by the scores; some clinical or practical judgment may be needed.



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FASD Wheel™ Case StudyLanguage may require a formal speech assessment; we screen language skills with the NEPSY:

Language Screening ScoreNEPSY Language: 81 (Borderline)

In this case, we only tested with the three NEPSY subtests. It was borderline, so no additional testing was needed for FASD diagnosis; however, we recommended further speech testing for interventions.





Memory can also be taken from several tests; older children and adults may also use the WMS-III:

Memory Scores

NEPSY Memory & Learning: 71 (Low)

WISC-IV Working Memory: 88 (Borderline)

Use the "worst" score again.





Motor skills can be obtained from tests of fine motor skills, from medical examinations, and from OT evaluations; we screen this with the VMI:

Motor Skills Screening Scores

VMI Overall Score: 75 (Low)

VMI Motor Supplement: 73 (Low)

Use the "worst" score again.



Work 13





Sensory and Soft Neurological skills are best obtained from medical exams and from OT evaluations; some tests can be screeners, e.g., NEPSY:

Sensory/Soft Neurological Scores

NEPSY Sensorimotor: 68 (Clinical)

NEPSY Visuospatial: 70 (Clinical)

OT evaluations are highly recommended.




FASD Wheel™ Case StudySocial Communication skills are best obtained from the BASC-2, ABAS-2 and the CELF-4 Pragmatics Rating Scale:

ScoresBASC-2 (Parent): 32 (Borderline)

ABAS-2 (Parent): 58 (Very Low)

ABAS-2 (Teacher 1): Borderline

ABAS-2 (Teacher 2): Borderline

Here, three Borderlines tend to overrule a Very Low; some clinical judgment here.




FASD Wheel™ Case StudyAdd in the mental health diagnosesand concerns:

ScoresDysthymic Disorder

Reactive Attachment Disorder

Posttraumatic Stress Disorder (probable)

Attention-Deficit/Hyperactivity DisorderIs covered by the Attention Domain ranking

These contribute to internal and external stressors and further impair functioning.



Work 14




The Formula for FASD FailureTry an intervention (especially a really verbal one)

When it doesn't work, try it again louder

When it doesn't work, try it about a hundred more times (it might even work once)

Get mad or frustrated or hopeless

Keep believing that your FASD person really can do what you're asking in the way that you're asking

4. Retrain Your Brain – Thinking Differently About FASD


Implementing The FASD Wheel™Think about interventions related to each domain before you need them.

Hang this on the refrigerator, give one to teachers and others.

THINK DIFFERENTLY:

What is really going on with the FASD Brain Damage?

How can I approach this differently?


Practical Application


Complete Your Own Wheel

Complete the blank wheel to gain a better understanding of your person with FASD Brain Damage

Consult a psychologist on completing this wheel, as some test results are labeled uniquely (e.g., BASC-2)


Good Frog – Bad Frog Re-Mix

When is she a good frog?

When is she a bad frog?

(Close your eyes and listen )…



Work 15


Q & A

Questions & Answers

Don‘t forget to see the whole elephant


More InformationMore on the wheel: www.FASDWheel.com

More on the FASD Elephant™ (plus info and podcasts!): www.FASDElephant.com

FASD advocacy organizations: www.mofas.org, www.nofas.org

Diane Malbin's website: www.FASCETS.org

Program for retraining kids' brains: www.kidscanlearn.net

http://www.fasdwheel.com/

http://www.fasdelephant.com/

http://www.mofas.org/

http://www.nofas.org/

http://www.fascets.org/

http://www.kidscanlearn.net/

Documents

IHS 2009 National Behavioral Health Conference August 6 ......The reason "they act the way they do" is Brain Damage Retrain your own brain to think in terms of Brain Damage Even when