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Fetal Alcohol Spectrum Disorder in Children & Adults: Interventions for Families & Caregivers
Fetal Alcohol Syndrome continuing education psychology CEUs

Section 17
Identifying and Working with FASD Teens

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This paper provides a brief review of Fetal Alcohol Spectrum Disorders (FASD), provides basic guidelines for identifying FASD teenagers, and offers some basic strategies that counselors and classroom teacher can use when dealing with the FASD teen.

FASD Teens in the Classroom: Basic Strategies
Fetal Alcohol Spectrum Disorder (FASD) is a pattern of growth deficiencies, craniofacial malformations; and central nervous system dysfunction that can occur in babies whose mothers drink alcohol during pregnancy (Jones & Smith, 1973). A number of criteria relate to FASD. When a child has experienced prenatal alcohol exposure but does not fulfil all of the criteria for FASD, he or she is given a diagnosis of Fetal Alcohol Effects (FAE) or Alcohol-Related Neurodevelopmental Disorder (ARND). The current conception of this disorder is that it falls on a continuum, and a new term, Fetal Alcohol Spectrum Disorders (FASD), has been suggested to include all people affected by prenatal alcohol exposure (Streissguth & O'Malley, 2000).

FASD is the most prevalent preventable cause of mental disability and has been identified as one of the leading known causes of birth defects and developmental delays (Loock, 1991). Finnegan and Kandall (1997) reported that at least 2.6 million alcohol-affected babies are born per year in the United States. The incidence of FASD in the United States is estimated to be approximately 1 in 100 births annually (Sampson et al., 1997).

Children with FASD exhibit a complex array of behavioural, social, emotional, and cognitive problems, through no fault of their own. Alcohol acts as a behavioural teratogen, altering the developing neurons in the fetus and potentially causing behavioural changes in the child (Sampson et al., 1997). This means that whether the mother was a constant frequent drinker, a binge drinker, or a light social drinker, the child's brain will be affected. The extent of the damage depends on several factors, including the amount of alcohol, the point in gestation at which alcohol was ingested, whether the father abuses alcohol and/or drugs (the quality of the sperm cells can also be affected, which may translate into attention and learning problems in the child: Cicero, 1994), and the genetic make-up of the mother and fetus.

Children with FASD grow up to be adolescents and adults with FASD. These children experience greater success with early, consistent intervention. However, we sometimes do not recognize their disabilities until they are older, and they miss being diagnosed. Teenagers with FASD present an even more complex picture because of their developmental life stage: typical adolescent behaviour can mask more serious developmental difficulties. For example, Streissguth (1997) aptly relates that

during these years, families are faced with the jarring recognition that their child is not fitting the expected pattern of development and is not "catching up." Parental panic and confusion, professional uncertainty in the absence of clear diagnostic information, peer group pressures for independence, decreased interest in school as success diminishes, and normally developing adolescent sexuality all conspire to destabilize whatever equilibrium was developed during childhood.

Problems that families face during this period involve many complex decisions: balancing dependence versus independence, maintaining control, setting expectations, differentiating what behavmal adolescence and what are caused by the FASD/FAE, and maintaining their own sanity. Problems that teenagers with FASD/FAE face during this period are increased failure and less satisfaction in academic classes, more social isolation as peer interactions are dominated by cliques, uncertainty or unrealistic expectations about what it means to grow up, and a looming sense of low self-esteem and depression. When adolescents have FASD/FAE yet have never been diagnosed, they can't figure out what's wrong. Furthermore, with their poor communications skills, they are, in fact, still dependent on a nurturing family who can listen to their nonverbal communications (p. 136).

Clearly, teens with FASD need integrated support. Every person in the teen's life can play an important role in helping him or her develop better compensatory strategies. Sometimes adults who work with FASD tends can feel overwhelmed (as do the teens!).

FASD in Brief
When a teenager has FASD, she experiences difficulty in all four domains of functioning: cognitive, behavioural, emotional, and social adaptation. Each student has individual strengths and weaknesses that need to be observed, recorded, and addressed. Many of these teens display exceptional abilities in one or two circumscribed areas, such as computers, music, art, writing, mechanics, or other skilled vocations. If we notice these strengths, we can capitalize on them to help the student develop her weaker areas.

Typically, FASD teens experience problems learning from past behaviour; they are impulsive and disorganized; they lack planning ability and display faulty logic. They have memory problems (storage and retrieval) and abstract reasoning problems, and they are much better at expressive than at receptive language (comprehension). Thus, they are likely to appear normal and may speak as though they understand, but if you ask them to explain the concepts to you, they will fail. Their performance is inconsistent, giving others the impression that they are unmotivated or lazy. These teens may also process information more slowly than their peers, and most have difficulty with abstract math concepts, money management, and time concepts. Their achievement and social skills, which include adapting to individual living situations, showing appropriate sexual behaviour, relating to peers and others, and understanding other people's emotions, are much lower than expected given their generally average IQs (Carmichael Olson et al., 1997; Carmichael Olson, Feldman, Streissguth, Sampson, & Bookstein, 1998; Geisler & Kandel, 1998). Sometimes they are perceived as having no conscience, but, in essence, what they lack is the ability to connect actions with consequences and the reasoning behind that ability (Thomas, Kelly, Mattson, & Riley, 1998). Malbin (1999) reports that a typical 18-year-old with FASD will respond emotionally and socially at the level of a seven-year-old. Thus, we cannot expect him to have the same social conscience that an average 18-year-old might possess.

The deficits noted above fall on a continuum of severity, such that every teenager, at some time, may experience these problems. With FASD teens, however, the difficulties are more consistent. Since many of these teens are never diagnosed, they are usually blamed for their problems, and they tend feel at fault, although they do not really understand why. This can cause the emergence of secondary problems such as depression, suicidal tendencies, anxiety, panic attacks, irritability, frustration, anger, aggression, lying, running away, legal trouble, and substance abuse. These secondary problems only serve to exacerbate the primary disabilities of these teens (Famy, Streissguth, & Unis, 1998; Streissguth & O'Malley, 2000).

FASD Students in the Classroom
If teachers or counsellors have concerns about a student, it is advisable to refer him for services to obtain the necessary extra support. In doing so, it is important to remember that the secondary problems are just as detrimental as the primary ones, although they are typically ignored (Baer, Barr, Bookstein, Sampson, & Streissguth, 1998; Famy et al., 1998; Streissguth, 1993). The FASD teen cannot progress academically or vocationally without addressing concerns related to problems such as depression, anxiety, difficulty coping with emotions, anger outbursts, and drug or alcohol abuse (Streissguth, Barr, Kogan, & Bookstein, 1997).

Ideally, the student should receive support from a team of individuals working together to support her development and learning. This team may include input from the student, parents (or foster parents), teachers, resource teachers, teacher's aides, school guidance counsellor, psychologist (or possibly neuropsychologist), social worker, nurse, physician/paediatrician, psychiatrist, speech pathologist, and occupational therapist (Streissguth, 1997).

A teacher should be able to talk with the student about his perceptions and academic difficulties. He may be feeling frustrated and unable to voice an opinion, but an observant teacher or counsellor may be able to get clues through non-verbal messages such as anger, throwing paper down, and gazing around the room (Burgess & Streissguth, 1990). Students can provide much-needed information about their needs, fears, likes, and frustrations. It is fascinating to be able to take time to observe students in the classroom. Their behaviour is a great source of information for understanding the motivations of FASD adolescents.

Additionally, once a student has been properly diagnosed with FASD, it may be useful to connect an advocate with the student. An advocate (student aide) for the teen would be most beneficial in helping both the teen and the teacher. The aide can serve as an intermediary to listen to both the student, about problems she may be experiencing with different teachers or ways of instruction, and to teachers about concerns they may have or comments about what works well. A communication book should be kept by the aide in order to mediate information between teachers, student, and parents (Burgess & Streissguth, 1990; Streissguth, 1997).

Peer support can be valuable in helping the FASD student learn about age- appropriate social interactions, making friends, and learning communication skills. Again, it is vital that the FASD student learn the same concepts in as many different environments as possible. Thus, learning communication skills with peers, teachers, parents, and others is most useful.

Tips for Teachers
We know that students with FASD have difficulty with abstract concepts, therefore, it is best to provide instructions in short, slow segments and to say exactly what you mean. These students do not understand humour or sarcasm. To assist with understanding, it is important to provide many concrete examples of the concepts being taught and, if possible, to present the information in many different modalities. Many of these students learn concepts through singing the ideas (e.g., to rap or rhyme) or moving while reciting the information. The more sensory modalities are used in making connections in concept formation, the better the student's chances of learning—plus, it makes learning more fun! The student has a better chance of learning the concept if a teacher can show how it works in their environment, that is, how it is meaningful to him (Streissguthet al., 1997).

Similarly, learning new skills and concepts is manageable if the skill is broken down into small steps, using examples that are interesting to the student. It is important to ask the student to explain what he is learning and to show the teacher what he has learned, as well as how he can put this concept into practice. However, it is important to realize that FASD teens are very good at reciting back what others tell them without really understanding what they are saying. Ask the student to indicate when certain strategies are working or are too difficult. When working on new concepts, it is important to incorporate awareness of emotions, feelings, or reactions to certain challenges or methods of instruction (Malhin, 1999; Streissguth, 1997).

FASD teens have difficulty coping with change. The best environment for them is predictable (routine), with a set schedule and a lot of structure. They need to begin to learn about change and adaptation to gain skills for living and working independently, but this is best done within a structured, familiar environment where they are gradually introduced to transitions. Malbin (1999) stresses that sometimes people confuse structure with control. These teens, like most, will not respond well to an overly controlling environment. Soliciting feedback is always important in understanding these students.

Another strategy for helping FASD students to strengthen their abilities is to focus on memory tasks. Helping students with memory tasks will allow them to learn to live independently. For FASD teens, repetition is the key. Teachers need to repeat information constantly to help ensure that some of it has been encoded. A daily planner can help the teen write down information she has trouble retaining, record key concepts, set priorities, and schedule tasks, as well as managing her emotions. Parents can be encouraged to help set up a system of entering information into the daily planner. This will also help with time management and organization and, eventually, life planning (Streissguth et al., 1994).

The ability to make associations between abstract concepts and to plan ahead are usually operations we take for granted. Students with FASD struggle every day trying to link concepts together. In order to learn associations, FASD teens need to be shown how concepts link, and, if possible, to be shown in different modalities (speech, writing, pictures, acting out). They need to observe appropriate behaviour being modelled in various situations; and then practise these skills over and over (Mattson & Riley, 1998; Mattson, Riley, Gramling, Delis, & Jones, 1998).

Corollary Issues for the FASD Student and Teacher
One of the most difficult issues facing an FASD adolescent is the inability to learn from previous behaviour, creating the potential for inappropriate personal and interpersonal relationships. Teens with FASD are often naïve and lack social skills. These difficulties become more apparent during the years when other adolescents are forming strong peer groups and learning about interpersonal relationships. In order to achieve any measure of success, FASD students need social skills training (Burgess & Streissguth, 1990). Social skills training must include lessons on communication skills—that is, how they should relate their needs and feelings to others and how to behave with others in a workplace or with friends. Because of their trusting nature, FASD teens are constantly taken advantage of by peers and others. They often get into trouble with the law because other kids tend to use them. As well, there is a very high risk of unplanned pregnancy among girls with FASD and a tendency for teens of both genders to behave in sexually inappropriate ways (and to be victimized sexually). They need to be taught about sexual development, birth control, and sexually transmitted diseases in order to be safe. Drug and alcohol education is also important, and referral for treatment may be necessary (Streissguth, 1997).

Similarly, an FASD student may experience stress born of both academic and personal difficulties. Anxiety can block learning. Many of these teens know they have difficulty learning and become anxious when new learning must take place. If they learn basic breathing and relaxation techniques for learning in the classroom, they can also learn to generalize this strategy to other areas of their life, for example, when feeling as though they might "explode" or lose their temper (Streissguth et al., 1997).

Typically, FASD students receive very little positive feedback; it is important to remember that a little encouragement really can go a long way with these teens. Furthermore, because they are so easily frustrated, encouragement will help motivate them to persevere until task completion. Most FASD teens lack self-esteem as a result of their awareness of their constant failures and their inability to "keep up" with their peers. A referral to the counsellor for help with self-esteem issues would not be unreasonable.

Further, although FASD teens are not socially mature, they are becoming physically mature and are reaching the age when they need to begin thinking about independent or semi-dependent living. Referrals to a guidance counsellor who can help direct the student towards appropriate job placement, spending sessions modelling appropriate communication skills, and writing out a specific concrete plan, always in conjunction with the student, can be helpful. A referral to an aide who can support the teen in learning money management, budgeting, and time management is essential.

As a teacher, counsellor, or other adult having dally interactions with FASD students, one can easily misinterpret what the student says or does and feel frustrated at having failed him. It is best not to personalize their behaviour, because they likely do not have sufficient coping strategies at this point to respond appropriately. The best advice is to write down these reactions, so that the student can begin to track behaviour and alternative strategies to use. Frustrations and blocks can be alleviated when we remind ourselves that the problem is one of organic brain damage. If a child has been hit by a car and suffers traumatic brain injury, we immediately modify our expectations regarding her abilities and performance. This should be equally true for FASD teens. Their brains have been traumatized. The fact that they have brain damage does not mean that intervention is hopeless and learning cannot occur but, rather, that we must modify the way we help them assimilate new information. Similarly, through the work we do, we can help these teens learn to take responsibility for those negative behaviours they exhibit and to learn to adapt them.

The importance of maintaining communication with both FASD teens and their parents cannot be stressed enough. The work you do needs to be repeated and reinforced by the parents, the advocate, the peer support worker, the teacher's aide. New concepts need to be practised in the student's community environment in order for consolidation to occur. My experience has been that working individually with these students, maintaining a genuinely non-judgmental, caring attitude and a consistent, structured environment, allows them to flourish. If each of us works individually with the FASD student in our areas of ability, and if we communicate as a team with students and parents, we will have a greater chance of helping the student towards a more successful future.
- Harpur, Lisa; FASD Teens in the Classroom: Basic Strategies; Guidance & Counseling; Fall2001; Vol. 17, Issue 1

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