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© FASCETS, Inc.
PPC TeleconferenceJanuary 27, 2015
Fetal Alcohol / Neurobehavioral Conditions: FA/NBTrying Differently Rather than Harder
Understanding and Application of a Brain-based Approach
Diane V. Malbin, MSW
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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?
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© 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
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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
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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
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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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© FASCETS, Inc.
© 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
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Comparison: Effects of drugs on prenatal development
Effects: Alcohol Cocaine Marijuana
Low birthweight
X X
Intellect,Development X
Organdamage X
Hyperactivity X XSource: US Department of Health and Human Services
X
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Keith L. Moore
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Myelin sheath
Dendrites
Nuclei
• Axons
Processes quickly
Many interconnections
Demyelination, processes slowly
Fewer interconnections
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Neurobehavioral screening tool
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Definition:Primary characteristics
Behavioral symptoms associated with differences in brain structure and function
Strengths are also primary characteristics
Source: Ann Streissguth, 1996
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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
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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
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Uneven development adolescent
Actual age of person: 18
Developmental age--------9
Strengths (art, sports)----------------------------24
Expressive language---------------------20
Receptive language----8
Reading ---------------------------14
Comprehension ------7
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Learning strengths
• Relational: 1:1
• Visual
• Auditory
• Hands-on
• Kinesthetic -- see, touch, move
• Experiential -- learns by doing
• Multimodal -- uses all senses
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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
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Anonymous, with permission
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Secondary behavioral symptoms
• Easily tired, fatigued
• Anxious
• Lonely, isolated
• Shut down; flat affect
• Fearful, withdrawn
• Depressed
• Frustrated, short fuse, angry
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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
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Accumulation of DSM diagnoses:Short list
Primary characteristics
Attention Deficit DisorderIntellectual Disability (Intellectual Dev. Disorder ICD 11)Language DisorderAutism Spectrum Disorder
Secondary characteristics
Reactive Attachment DisorderOppositional Defiant DisorderPost-traumatic Stress Disorder / TraumaGeneralized Anxiety DisorderPersonality Disorder
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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 abilityStrategy example: Talking
Assumptions about Brain function: Store information……………….Retrieve information……………Form associations………………Abstract………………………….Generalize……………………….Predict……………………………Conceptualize…………………..Process quickly………………….
Research on FA/NB hasFound brain differences:
Difficulty with memoryDifficulty retrieving informationDifficulty forming links Concrete Difficulty generalizingDifficulty predictingGets piece, not pictureProcesses slowly
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Behavioral techniques based on learning theory are used in all
systems:
ParentingEducation
JusticeMental health
Addictions treatmentSocial services
Others
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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?
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Between sessions activities
Next month’s teleconference will focus on shifting thinking and
developing strategies. It will be based on observations
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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 happened1. 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, learn 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
Listen, learn 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
Listen, learn 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
Listen, learn 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
Listen, learn 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
Listen, learn 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
Listen, learn 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
Listen, learn 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.
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
14 May not finish assignments
Artistic, experiential
Art, drama, music, relationship, role modeling
Communicate Process language
Slow processing pace
12 Anger, frustration
Determinedcreative
Art, drama, music, poetry
Apply new knowledge
Store, retrieve and generalize
Memory problems, difficulty generalizing
16 Defensive Relational Teach in different settings, use mentor
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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
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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
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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 69242Portland, OR 97239
www.fascets.org