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Bingeman’s (KidsAbility Forum)
Waterloo, Ontario
November 21, 2013
Linking brain function with behaviors:
Understanding and application of a
brain-based approach
Diane V. Malbin, MSW
© FASCETS, Inc.
Universal
• Research from around the world is
consistent
• Regardless of nation or culture, education
or income, prenatal exposure affects
brains
• The question is: What does it mean for
you? Your work? Your community?
What if?
© FASCETS, Inc.
© FASCETS, Inc.
Logic model
Is FA/NB a physical condition?
1. Genetics, trauma, and a wide range of
teratogens and events cause physical changes
2. Alcohol kills cells, including in the brain
3. Alcohol and other drugs affect the structure and
function of the brain
4. Behaviors are usually the only symptoms
5. FA/NB is an invisible physical disability with
behavioral symptoms
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.
Specific points about FASD
1. FAS = leading cause DD in Western world
2. 90-100% FASD (and FA/NB) still not diagnosed
3. 1-3/1,000 = FAS (facial features require alcohol exposure
between days 18-21 of gestation)
4. 3-5% births = FASD in Western World
5. FASD with no facial features at greater risk
6. 80% of all people drink, 50-75% pregnancies unplanned
7. 16-35% of all pregnancies “at risk” (Jones)
8. Average IQ 74; range 20-130
9. Epigenetics research, paternal effects (Greengard 2010)
© FASCETS, Inc.
Importance of Identification
• Pivotal: Brain-based physical condition
• Identifies etiology
• Reframes the meaning of behaviors:
From won’t to can’t
• Redefines the nature of the problem
• Redefines focus for interventions
• Key for prevention
© FASCETS, Inc.
Examples of success
Artist, musician
Warehouse person
Electrician
Boat builder
Mechanic
Child care worker
Animal rescue worker
Drummer, dancer
BA, BS, MA, MSW, PhD
Office worker
Special ed. teacher
Counselor
Massage therapist
Truck driver
Husband, wife: Parents
Delivery person
Parent
Adult care worker
Neurobehavioral Foundation
What’s the brain got to do,
got to do with it?
© FASCETS, Inc.
Pre- and postnatal events
affecting brain development
1. Exposure to teratogens, including
alcohol and other drugs
2. Illness
3. Traumatic brain injury
4. Severe abuse, trauma and/or neglect
© FASCETS, Inc.
Alcohol Drugs Tobacco TBI Genetics Illness Anoxia
Brain function Memory problems
Executive functioning
Processing
Different source, similar symptoms?
© FASCETS, Inc.
© FASCETS, Inc.
Myelin sheath
Dendrites
Nuclei
Axons
Processes quickly
Many interconnections
Demyelination, processes slowly
Fewer interconnections
© FASCETS, Inc.
© FASCETS, Inc.
© FASCETS, Inc.
© FASCETS, Inc.
Comparison:
Effects of drugs on prenatal development
Effects: Alcohol Cocaine Marijuana
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.
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.
© FASCETS, Inc. From: Life before birth
© FASCETS, Inc.
Photo courtesy of Sterling Clarren, MD
© FASCETS, Inc.
Photo courtesy of Sterling Clarren, MD
© FASCETS, Inc.
Photo courtesy of Sterling Clarren, MD
© FASCETS, Inc.
Alcohol Health and Research World
© FASCETS, Inc.
Scientific American 1995
© FASCETS, Inc.
Scientific American 1995
© FASCETS, Inc.
Scientific American 1995
© FASCETS, Inc.
Scientific American 1995
© FASCETS, Inc.
FASD is an invisible physical disability
Brain changes = behavioral changes
© FASCETS, Inc.
Brain break: Fjord, Norway
Primary and secondary
behavioral symptoms and
tertiary problems
© FASCETS, Inc.
Definition:
Primary neurobehavioral symptoms
Behavioral symptoms of underlying brain structure and function, including strengths.
Source: Ann Streissguth, 1996
© FASCETS, Inc.
Primary neurobehavioral symptoms
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)----------------10
Expressive language------------8
Receptive language-2
Reading ------------------4
Comprehension ----3
© FASCETS, Inc.
Uneven development adolescent
Actual age of person: 16
Developmental age--------8
Strengths (art, sports)----------------------------22
Expressive language---------------------20
Receptive language----6
Reading ---------------------------12
Comprehension ------5
© FASCETS, Inc.
Functional and academic deficits:
Adolescents and Adults with FASD
Vineland Chronological Age Developmental
Mean Age Equivalent
Adaptive Behavior 16.6 9.1
Communication Skills 16.6 9.0
Daily Living Skills 16.6 10.1
Socialization Skills 16.6 7.5
PPVT Receptive Language 16.6 6.8
Source: Streissguth 1996
© FASCETS, Inc.
Primary behaviors: Strengths
Artistic
Musical
Mechanical
Athletic
Creative
Determined
Willing
© FASCETS, Inc.
Learning strengths
• Relational: 1:1
• Visual
• Auditory
• Kinesthetic, multimodal, hands-on
• Experiential, learns by doing
© FASCETS, Inc.
Definition:
Secondary behavioral symptoms
Defensive behaviors that develop over
time when there is a “poor fit”
Defensive behaviors are normal reactions to pain and
frustration and may be prevented or resolved
Adapted from: Ann Streissguth, 1996
© FASCETS, Inc.
Drawing by mother of 15-year-old
© FASCETS, Inc.
Drawing by 15-year-old with FASD
© FASCETS, Inc.
Secondary behavioral symptoms
• Easily tired, fatigued
• Anxious
• Lonely, isolated
• Shut down; flat affect
• Fearful, withdrawn
• Depressed
• Frustrated, short fuse, angry
© FASCETS, Inc.
Organized, efficient less energy required for task
Conner, et al 2005
PET Scans: The better the brain is organized, the less
energy is required to do the task
© FASCETS, Inc.
Organized, efficient FAS: Disorganized, less
less energy required for task efficient, more energy
Conner, et al 2005
PET Scans: The greater the disorganization, the harder
the entire brain works, causing fatigue and irritability
© FASCETS, Inc.
Poor fit
FASD Characteristic
Visual learner………..........
Processes slower…………
Needs external support….
Difficulty organizing………
Concrete……………..........
Technique, values
Verbal instruction
Fast paced
Work independently
Organize, prioritize
Abstract
© FASCETS, Inc.
Good fit
FASD Characteristic
Visual learner……………..
Processes slower…………
Needs external support….
Difficulty organizing………
Concrete……………..........
Technique, values
Provide visual cues
Allow adequate time
Provide supports
Provide structure
Experiential, build on
strengths
What strategies are used to try to
change behaviors?
© FASCETS, Inc.
Current practice
Learning theory assumes
the ability of the brain to:
Store information…….…….
Retrieve information………
Form associations…………
Abstract…………………….
Generalize………………….
Predict………………………
Conceptualize……………..
Process quickly…………….
Research on FASD has
found:
Difficulty with memory
Difficulty retrieving information
Difficulty forming links
Concrete
Difficulty generalizing
Difficulty predicting
Gets piece, not picture
Processes slowly
© FASCETS, Inc.
What systems use cognitive behavioral
approaches?
Parenting
Education
Justice
Mental health
Addictions treatment
Social services
Others
© FASCETS, Inc.
There’s nothing wrong with the technique
The problem:
Assumptions about brain function are not
usually examined for their fit with actual
brain function
The bigger issue is that the problem
definition misses the mark: Brain function
© FASCETS, Inc.
Paradox
• Good techniques, poor fit = Try harder: Behaviors deteriorate
• Recognize brain function, provide accommodations: Secondary behaviors resolve
• The goal is the same, approach paradoxical
Emotional reactions to behaviors
Where do these come from?
Why so strong?
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
Dysmaturity
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
Dysmaturity
Act your age
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
Dysmaturity
Act your age
Being a baby,
Lazy, not trying
Frustrated
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
Dysmaturity
Act your age
Being a baby,
Lazy, not trying
Frustrated
Punish
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
Dysmaturity
Act your age
Being a baby,
Lazy, not trying
Frustrated
Punish
Anxiety, anger
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
Dysmaturity
Act your age
Being a baby,
Lazy, not trying
Frustrated
Punish
Anxiety, anger
Think younger
Adjust expectations
© FASCETS, Inc.
Values and values clashes
Primary
characteristic
Values,
expectations
Interpretation /
Feelings
Intervention Secondary
symptom
Accommodation:
Build on
strengths
Dysmaturity
Act your age
Being a baby,
Lazy, not trying
Frustrated
Punish
Anxiety, anger
Think younger
Adjust expectations
Confabulation
Honesty
Lying,
manipulative,
“At me”
Fear, angry sad
Punish, ground
Anger, denial
Recognize brain
dysfunction, alter
communication
Memory
problems
Remember
“Should” know!!
Angry frustrated
Remove
privileges
Anger, frustration
Accept need to
reteach, based on
learning strengths
Slow processing
pace
Value speed –
think fast
Not trying,
withholding ,
on purpose
Angry, frustrated
Speed up, yell,
embarrass
Shut down, fear,
avoidance,
withdrawal
SLOW DOWN!
Use fewer words
Difficulty
generalizing,
gets the piece,
not the picture
Know and apply
concepts in
different settings
Breaking the rules,
Should understand
concepts in all
settings
Angry, frustrated
Consequence
Confusion,
anxiety,
frustration
anger
Show rather than
tell, reteach in
different settings
© FASCETS, Inc.
Overlapping Diagnoses
© FASCETS, Inc.
Paradigm in Practice
We see what we look for
We look for what we know.
Goethe
© FASCETS, Inc.
Contributions and limitations of the
DSM
• FASD is not in the DSM (Is in appendix, DSM 5)
• DSM organizes presenting symptoms
• DSM provides reliability
• Etiology is required for validity
• DSM provides reliability without validity
(Adapted from Andreasen, MD PhD)
Multiple diagnoses often cause confusion,
rather than contribute clarity
© FASCETS, Inc.
New DSM 5: Critiques
New DSM-5 Ignores Biology of Mental
Illness Scientific American: 4/30/2013
“…symptoms alone rarely indicate the
best choice of treatment….Patients with
mental disorders deserve better.”
Thomas Insel, MD, Director NIMH: 4/29/2013
© FASCETS, Inc.
Neurobehavioral disorder associated with
prenatal alcohol exposure (ND-PAE)
“…Essential features are the manifestation of
impairment in neurocognitive, behavioral and adaptive
functioning”
Proposed criteria:
• More than minimal exposure to alcohol during
gestation…
• Impaired neurocognitive functioning
• Impaired self-regulation
• Impairment in adaptive functioning
DSM 5 appendix, p 798
© FASCETS, Inc.
Accumulation of Diagnoses:
Select list
Primary symptoms:
Failure to thrive
Pervasive Developmental Delay
Speech and Language Delay
Attention Deficit Disorder
Secondary symptoms:
Reactive Attachment Disorder
Oppositional Defiant Disorder
Post-traumatic stress disorder / trauma
© FASCETS, Inc.
Current model
ADD
LD
ODD
PDD
PTSD
RAD
Multiple diagnoses, fragmentation
Autism
© FASCETS, Inc.
FASD is not a differential diagnosis
ADD
LD
ODD
PDD
PTSD
RAD
Autism
ND/PAE
© FASCETS, Inc.
Brain-based model
ADD
LD
ODD
PDD
PTSD
RAD
The brain is the organizing principle
Autism
Brain function
© FASCETS, Inc.
Level of expectation
Chronic discrepancy
Birth Average level of performance
Development of Burnout
Visual based on Freudenberger
© FASCETS, Inc.
Actual levels of performance
Inconsistent performance
Random Reinforcement
© FASCETS, Inc.
1. Gap
2. Judgment
Anger, punishment, defenses, rigid defenses
Brain
Person
© FASCETS, Inc.
No information Identification Resolution
Fear, anger, frustration
Sadness, guilt, depression
Understanding, peace
© FASCETS, Inc.
Adjusting expectations
The better the fit between expectation and ability, the less stress
Level of expectation
Ability
© FASCETS, Inc.
It really looks more like this…
Brain function trumps behaviors
© FASCETS, Inc.
Where there is anger, frustration
or blame: There is missing
information
What is the question?
© FASCETS, Inc.
Paradigm: Way of seeing
Paradigm shift: Seeing differently
”I get it…she has the disability.
We have to do the changing.
Source: Parent of child with FASD
© FASCETS, Inc.
Paradigm Shifts and FASD
From:
Won’t…………………….
IS the problem…..……..
Doesn’t work…………...
Acts immature………….
Doesn’t try……………...
To:
Can’t
HAS a problem
Has trouble starting
Is dysmature
Tired of failing
© FASCETS, Inc.
Virginia Lake, Sauvie Island
Photo by Ariel Malbin
Creating a goodness of fit
to prevent problems:
Application of a Neurobehavioral
approach
© FASCETS, Inc.
Is the goal for everyone to fit in?
X x
X
x
X
© FASCETS, Inc.
What if that’s not an option?
O
O
O
O
X x
X
x
X
© FASCETS, Inc.
What happens?
O
O
O
O
X x
X
X x
© FASCETS, Inc.
Brain-based approach: everyone fits
O
x x
O O
x x O
X
O
Celebrates cognitive and cultural diversity
© FASCETS, Inc.
I hear and I forget
I see and I remember
I do and I understand
Proverb
© FASCETS, Inc.
Explore Environments
Physical elements
“Invisible” elements
© FASCETS, Inc.
Tangible Physical Elements
Affecting sensory systems
Sight: Lighting, decorations, distractions
Sound: Noise level, buzzing, interruptions
Smell: Lunchroom, bodies, perfume
Touch: Textures, objects, proximity, furniture
© FASCETS, Inc.
© FASCETS, Inc.
“Invisible” elements: Smorgasbörd
Values, norms, expectations, timelines
Schedule, changes in routine
Age-based expectations and grouping
Instructional technique, level of abstraction
Language-based instruction
Bell curve, competition
Learning theory, shared perceptions, systems
homeostasis
Parenting and professional curricula
© FASCETS, Inc.
Comparison of Environments:
Controlling
Work at the person……
Punish………………….
Coerce………………….
Rigid…………………….
Top down, power play..
Tell……………………...
Alienate…………………
Structured
Work with the person
Prevent
Collaborate
Flexible, resilient
Reciprocal, relational
Ask
Relate
Keep it simple
A functional neurobehavioral assessment
FNA: Person, setting and fit
© 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
Sit still and
listen
© 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
Sit still and
listen
Process
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
Sit still and
listen
Process
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
Sit still and
listen
Process
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
Sit still and
listen
Process
fast
Slow
processing
pace
3
Frustration
© 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
Sit still and
listen
Process
fast
Slow
processing
pace
3
Frustration
Visual
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
Sit still and
listen
Process
fast
Slow
processing
pace
3
Frustration
Visual
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
Sit still and
listen
Process
fast
Slow
processing
pace
3
Frustration
Visual
learner
Provide visual
cues, use fewer
words
Be age-
appropriate
Develop
“on time”
Dysmaturity 3 Isolation
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
Sit still and
listen
Process
fast
Slow
processing
pace
3
Frustration
Visual
learner
Provide visual
cues, use fewer
words
Be age-
appropriate
Develop
“on time”
Dysmaturity 3 Isolation
Depression
Willing,
relational
Adjust
expectations,
“Stretch toddler”
Sit and
learn, paper
and pencil
Ability to
abstract
Concrete,
difficulty
with
abstraction
2 Anger,
frustration,
avoidance
Learns by
doing
Hands-on
Kinesthetic
© FASCETS, Inc.
“Repurposing” Mental Health Tx
Current practice
• Secondary symptoms = problem
• Burden on tx providers to “fix”
problems
• Values-laden interpretations:
Symptoms targeted for change
• Brain function typically not
factored in to tx plans, goals
• Tx programs typically cognitive,
language-based
• Accumulated diagnoses, repeat
admissions
Repurposed
• Brain: Identify etiology, strengths
• Reframe problems and solutions
• Create conditions for “settling”
• Research-informed
understanding
• Expand tx goals, techniques
• Engage, educate others post-tx
• Assure seamless transitions,
sustained conditions for health
© FASCETS, Inc.
What is the question?
• The first questions are always:
• Who is the person?
• What if? What about brain function?
• What is the fit?
• Whose needs are being met?
© FASCETS, Inc.
Observe to Find Patterns: Functional neurobehavioral assessment
• Are behaviors primary or secondary?
• Observe without interpreting
• What did you see?
• What happened just before?
• Describe the setting, environment
• Were there other factors? E.g.
unexpected change?
© FASCETS, Inc.
Cliff notes: Starter strategies
1. Stop fighting, step back, breathe
2. Ask what if? Think brain
3. Slow down, give time: 10-second kid
in a 1-second world
4. Think younger
5. Observe, adapt
6. Show, repeat
7. Keep it super simple
8. Be gentle with yourself
© FASCETS, Inc.
Accommodations
1. FASD is an invisible physical disability
2. Changes in the brain are physical
3. Behaviors are symptoms
4. Trying harder to change neurobehavioral symptoms exacerbates frustration
5. Recognizing brain function and providing accommodations prevents problems
6. This is the same principle as for people with more obvious disabilities
7. It works
© FASCETS, Inc.
Emerging best practices
British Columbia’s province-wide,
cross-Ministry application of this
neurobehavioral model
BC MCFD web site with FASD evaluations
http://www.mcf.gov.bc.ca/fasd/index.htm
© FASCETS, Inc.
Diane V. Malbin, MSW
FASCETS
PO Box 69242
Portland, OR 97239
www.fascets.org