Behavioral & Environmental Strategies for Working with Fetal Alcohol-Exposed Youth

Behavioral & Environmental Strategies for Working with

Fetal Alcohol-Exposed Youth

Introduction

Jody Allen Crowe –served as teacher, principal, superintendent.

18 years experience in tribal schools Minnesota and western states.

Director of Studio Academy High School Executive Director – Healthy Brains for

Children

Dilemma

Not a doctor, psychologist, psychiatristA manLearned what I know on reservationsEducator – the only profession that analyzes the brain function of every child over a long period of

time.

Seeing-Eye Brain

What are the mitigating factors in your client’s lives?

Of all the mitigating factors in your

client’s life, what can you control?

Environment

Food

Yourself

What are we talking

about?

Ethanol kills brain cells of the fetus.

The ‘Inconvenient Truth”

Alcohol is a Teratogen

Permission to use photo on file.

Alcohol Added to Unhatched Eggs

Sulik et al

When does the damage occur?

Eyes Weeks 3 1/2 to full term

Central Nervous System2 weeks to full term Ears

Weeks 4 1/4 to 20

Teeth Weeks 6 3/4 to full term

Palate Weeks 6 ¾ to 16

Upper limbsWeeks 2 1/2 to 9

External genitalia Weeks 7 to full term

Lower limbs Weeks 3 to 9

Heart Weeks 2 1/2 to 9

Jody Allen Crowe 2010

CELLS THAT SHOULD FORM MIDLINE STRUCTURES OF THE BRAIN AND FACE ARE

KILLED BY ALCOHOL

Developingbrain and

face

Heart

Mouse embryo (viewed from the front) at a stage corresponding

to a 22-23 day old human.

A close-up view of an alcohol-exposed mouse embryo shows cells killed by alcohol

that have taken up a dark blue stain.

6

General Intellectual Performance

FSIQ VIQ PIQ40

55

70

85

100

115

Sta

nd

ard

sco

re

IQ scale

NC

PEA

FAS*

**

**

**

Mattson, S.N., 1997.

Neuropsychological Performance

FSIQ Read Spell Arith PPVT BNT ATotal VMI PegsD CCT40

50

60

70

80

90

100

110

120

Measure

CON

PEA

FAS

Mattson, et al., 1998

2

1

3

1

2

3

Group0

2

4

6

Ru

le V

iola

tion

s

NC

PEA

FAS

P<0.001

Move only one piece at a time using one hand and never place a big piece on top of a little piece

Starting position

Ending positionMattson, et al., 1999

Executive functioning deficits

Stages of Prenatal Exposure to Alcohol

0 1 2 3 4 5

No prenatal exposure to

alcohol

Prenatal exposure to alcohol with

loss of potential not observable

with current tools

Prenatal exposure to

alcohol resulting in detectible lowered

academic, social and emotional

intelligence.


alcohol resulting in observable

exhibitions of brain damage

behaviors, which result in

academic failure,

psychological diagnoses,

criminal behaviors, depression


alcohol resulting in

physical manifestation

and observable exhibitions of

Stage 3 academic and

social brain damage

behaviors


alcohol resulting in miscarriage,

stillborn, SIDS, death

due to organ failure

damage from prenatal

exposure to alcohol.

Crowe 2010

Stages of Prenatal Exposure to Alcohol

0 1 2 3 4 5

No prenatal exposure to

alcohol

Prenatal exposure to alcohol with

loss of potential not observable

with current tools


alcohol resulting in detectible lowered

academic, social and emotional

intelligence.


alcohol resulting in observable

exhibitions of brain damage

behaviors, which result in

academic failure,

psychological diagnoses,

criminal behaviors, depression


alcohol resulting in

physical manifestation

and observable exhibitions of

Stage 3 academic and

social brain damage

behaviors


alcohol resulting in miscarriage,

stillborn, SIDS, death

due to organ failure

damage from prenatal

exposure to alcohol.

Crowe 2010

There is no ‘Silver Bullet.’There are no ‘Standard Operating

Procedures.’There is no template.

But,there are commonalities and

there are ‘Best Practices.’

Behaviors that cause disrupted school experiences can be linked to functions of the

brain called

Executive Functions

Phineas Gage and Executive Functions of the Brain

Before the accident

hard-working, responsible, and popular with his workers

well-balanced mind a shrewd, smart businessman

very energetic and persistent in executing all his plans of operation

Fitful, irreverent, gross profanity Obstinate, impatient, did not like adviceGrandiose plans with no follow-throughA child in intellect, with animal passions of a strong man.

Shocking device

Impulse Study using RatsFrontal Lobe Damage/Executive Functions

Impulse Study using RatsFrontal Lobe Damage/Executive Functions

Shocking device

Moral CompassProblem solvingImpulse controlSelf MonitoringRegulation of Sexual UrgesInhibitions Verbal self-regulationRegulation of emotion JudgmentReasoningFocused AttentionEmpathy

Executive Functions of the Frontal Lobes

Connecting an action to a consequence

Limbic System of the Brain

Damage to the corpus collosum interferes with the ability to pass information from the left to

right hemispheres and between various components of the brain.


The basal ganglia, a group of structures around the thalamus, are important for voluntary

movement and voluntary thought, a funnel, so to speak, where thought gathers.


Thalamus plays a major role in regulating arousal, levels of awareness, and activity.


Hypothalamus is one of the most worked parts of the brain. It is responsible for regulation of

hunger, thirst, pain, pleasure, sexual satisfaction, anger, etc.


Amygdala plays a response role. Electrical stimulation of this area cause rage and anger,

while a removal of this area will cause indifference towards such stimuli as fear, anger

and sexual pleasure.


Hippocampus is used in converting short-term memory information into long-term.

Exhibition of Limbic System Damage

Interferes with the ability to pass information from the left to right hemispheres and between various components of the brain.

Lowered ability to retain information in memory. Lowered reaction to fear of strangers and dangerous

events or situations. (Instant friends) Limited control of appetite, emotions, temperature, and

pain sensations. Perseverative behaviors, “thick thinking.” Lowered ability to process emotional reactions. Sensory integration issues.

Couple a day

Binge drinker

Heavy everyday drinker

No drinking

Occasional drink

Stopped at 6 weeks

First Trimester

Chart Title

Examples of Variability from Brain Damage Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding

Reading Comprehension

0

10

20


Couple a day

Binge drinker


No drinking

Occasional drink

Stopped at 6 weeks

First Trimester

Chart Title

Examples of Variability from Brain Damage Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20


Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20


Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20


Couple a day

Binge drinker


No drinking

Occasional drink

Stopped at 6 weeks

First Trimester

Chart Title

Examples of Variability from Brain Damage

Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20


Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20

Our court system is looking at this adolescent through this lens.

When functionally, we should be looking at this…..

Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20

Couple a day

Binge drinker


No drinking

Occasional drink

Stopped at 6 weeks

First Trimester

Chart Title

Stage 3 or 4


Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20

Couple a day

Binge drinker


No drinking

Occasional drink

Stopped at 6 weeks

First Trimester

Chart Title


Examples of Variability from Brain Damage

Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20

You might be working with this profile.Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20


So we ask ourselves.

Most will be able to identify consequence when prompted or after the fact.

Many have an immediate impulsive response without considering consequence.

Some can’t make a connection between parts of the brain that link an action to a

consequence.

Is this behavior Willful Disobedience or Brain Damage Behavior?

Maybe you can relate

Some common behaviors needing behavioral management

ADHD Arguing –Preseverative Behavior

Bad temper-violent behavior Lack of empathy Verbal outbursts

Lying Sexual promiscuity

Sexual predator Alcohol and drug use Depression/self abuse Threats of violence

Not accepting responsibility for actions

Arguing with an adolescent is like mud wrestling with a

pig. You both get dirty and the pig loves it.

If you want to change an adolescent’s behavior, you have to change how your behavior.

What Can You Do?

Always think brain damage first.

Whenever confronted by behaviors that are characteristics of prenatal exposure to alcohol, ask yourself if this is a result of brain damage.

Environment

EnvironmentWill a change in environment change the behavior?

Review all incidents to see if adults contributed to the student behavior.

Is the behavior a result of the inability to habitate?Inability to adjust to stimuli. (sounds, light, hot, cold, smell)

Interaction , proximity to others, language used by others.

Environment Control Strategies

Minimize chaos.

Minimize transitions.

Check to see that reading levels of displayed posters and reading materials are at the level of the

clients.

Minimize unexpected sensory inputs as much as possible.

Understand behaviors brought on by inability to habituate sensory inputs.

Systemic Consistency

No more than 5 expectationsDefine expectations - ex. respectTeach expectationsPost expectations in common areas Identify the consequences of not meeting

the expectationAll staff consistently follow systemFollow through

Acknowledge positive behaviors

At least a 3 to 1 positive to negative response from adult

What is learned in one environment may not transfer to

another environment.

Regardless of the Behavioral Program, you need to understand:

-the function of the behavior-how your actions impact the

behavior-what responses work with which

behaviors

Understanding the Function of the Behavior

We think they think the way we think they should

think.We have to change how we think they think.

Understanding the Function of the Behavior

Every behavior has a function – some behaviors are a function of brain damage

Raging –function is to remove the individual from a situation that is stressing the brain, for example the

inability to habituate.

Is it willful or brain damage behavior?Willful behavior can be based on faulty brain damaged

thinking.

Lying – brain damage behavior – sometimes hard to determine function

Your actions1. Communication

The brain damage may have interfered with the brains ability to process information quickly.

The brain may be coping with what you are saying without noticing the nonverbal communication, or may be

trying to decipher the nonverbal without being able to follow the verbal communication.

Its not only what you say, it is how you say it.

Be Careful using Figurative Speech in a conversation with a Concrete Thinker

Hyperbole-exaggerationI have told you a million times today

I’ll get to you in a second.

MetaphorDid I throw you a curve?

Did that throw you for a loop?

Sarcasm- verbal ironywhere the intended meaning of a statement differs from the

meaning that the words appear to express. I need this like a hole in the head!

Don’t let the door hit you on the way out.

Nonverbal communication

Do not assume the adolescent can read non-verbal communication.

Many prenatally exposed brains struggle with reading non-verbal communication.

If you use non-verbal communication for behavioral management, teach before using.

Check for understanding.

Sequence of Directions

A common difficulty is following sequenced directions.

Give one direction at a time.

Provide visual cues for a sequence of directions.

Why don’t you act your age?

You don’t remember. Yes, you do. We just did that yesterday!

How many times do I have to tell you?

What do you think I am? A bookstore?

Remember, your behavior might be the trigger event. Shaming and blaming language may push the damaged brain into actions that lead to trouble for the adolescent.

Shaming and Blaming Language

Your Actions2. Responses to behaviors

The most effective strategy to change behaviors are:

Verbal reminder and Prompts in a non-shaming, non-blaming manner

You are giving the damaged brain the opportunity to re-set.

Become the “Seeing Eye Brain”

Responses, cont.

Use prompts and reminders

for all behaviors except aggressiveness. In these cases, use verbal reprimand and cool

down strategies.

Chasnoff

Responses, cont.

Token economies work for: Withdrawal, shyness (over controlled

behaviors) Task completion Disobedience Attention problems, off task, impulsiveness

(under controlled behaviors)

Responses, cont.

If dealing with this brain damage

is frustrating for you, think of how frustrating it is for the adolescent.

Adjust Your Expectations

Responses, cont.

Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20

Remember, you have the option to look at your clients like this

Or like this.Chronological Age

Emotional Age

Expressive Language

Social Maturity

Executive Functions

Sexual Maturity

Math Skills

Memory Skills

Reading Decoding


0

10

20


Attitude

Be positive rather than punitive. Be supportive and respectful.

Encourage healthy, respectful behaviors rather than look for behaviors to punish.

Watch what behavior you model.

Responses, cont.

Use Consequences With Care Consequences must be concrete and simple

and must be applied immediately and consistently.

The adolescent may not learn, or may forget or make the same mistake again.

Adapt consequences to the child’s functional age rather than actual age.

Responses, cont.

Reprimands and praise

If done in front of others, expect a response that is designed so the recipient will not “lose face” in front of the others.

Many times praise in front of others is counter productive.

One on one or quiet contact in presence of others more effective.

Restraints Always be prepared to protect others and the

adolescent with restraint if need be. Review any restraint event to see if the adult’s

behavior contributed to the behaviors that led to the restraint.

As soon as the adolescent is compliant, move to cool down.

Determine the function of the behavior that led to the restraint. The function might be the need for physical

contact.

The Theory turned into PracticeSchool wide Behavioral Management System

Non-Shaming, Non Blaming Common language Ask questions to bring the brain back to focus Never try to argue or use logic when the

adolescent is raging When the adolescent is coming down from a rage,

explain the expectations to another adult without talking directly to the child

Agree to step in when another adult is not using the common language or is confrontational

QuestionsDefine and clarify each question

before using system Was that noise?

Was that out of place? Was that physical contact?

Was that off task?

Use of questions designed to give brain a prompt to move back into appropriate behavior pattern.

Physical Positioning

Proximity

Confrontational

Non-confrontational

Behavior Chart

Normal behavior

QuestionsIs that out of place?Is that noise?Is that off task?Is that physical contact?

Triggerevent

Do not argue!Use only direct

statements. Using logic does not work.

Ask questions three times before changing to statement.

Behavior Modification

Use self analysis toolDetermine increments of time

2

G

G P

P

1

P

G

0

Student

Teacher

Score

Increase increments of time as the student shows the ability to analyze and manage their own behavior

Thoughts Understand medication does not cure, but in many

cases creates a better learning experience Understand every child is at a different spot on the

Spectrum Always think ‘Brain Damage’ Understand academic difficulties are real and a

source of secondary disabilities

Never assume what is learned in one situation or environment will

transfer to another situation or environment.

Always remember this is lifelong brain damage.

Understand the damaged brain, when under stress or in unfamiliar circumstances, may revert to the illogical thinking that brought him/her into this

setting in the first place.

A small percentage of prenatally exposed children, adolescents, and adults are violent.

But……

Most violent children, adolescents, and adults have been prenatally exposed to alcohol.

In my professional opinion:

BEAM

Behavior Environmental Adaptation Model

The 15 BEAM Rules of FASD Behavior Management

Also known as the Fasstar Trek Model

© 2004 Teresa Kellerman

Websites

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Behavioral & Environmental Strategies for Working with Fetal Alcohol-Exposed Youth