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 Activity Take 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 )…
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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 )…
FASD: A New Model for Achieving
Consistent and Creative Interventions that
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
FASD: A New Model 11
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
FASD: A New Model 12
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
FASD: A New Model for Achieving
Consistent and Creative Interventions that
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FASD: A New Model 13
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.
FASD: A New Model 14
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)
FASD: A New Model 15
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
FASD: A New Model 16
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
FASD: A New Model 17
Brain Development: Repetition
A "cartoon" example of learning from repeated experience: Memorization
FASD: A New Model 18
Brain Development: Intensity
A "cartoon" example of learning from intense experience: A hot stove
FASD: A New Model for Achieving
Consistent and Creative Interventions that
Work 4
FASD: A New Model 19
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
FASD: A New Model 20
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"
FASD: A New Model 21
Example: Acute Stress Response
Reality check: The amygdala also signals our higher-level thinking centers
FASD: A New Model 22
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: A New Model 23
FASD = Brain DamageExample of "normal brain" (left)
With "normal" brain circuits
Extreme example of FAS brain (right)
With garbled brain circuits
FASD: A New Model 24
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
FASD: A New Model for Achieving
Consistent and Creative Interventions that
Work 5
FASD: A New Model 25
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
FASD: A New Model 26
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
FASD: A New Model 27
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
FASD: A New Model 28
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: A New Model 29
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
FASD: A New Model 30
The FASD Wheel™
Divide a circle into 10 sections:
Each sectionrepresents aBrain Domain
FASD: A New Model for Achieving
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FASD: A New Model 31
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
FASD: A New Model 32
The FASD Wheel™Normal functioning FASD functioning
FASD: A New Model 33
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
FASD: A New Model 34
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
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
FASD: A New Model 42
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)
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
FASD: A New Model 52
10. Social CommunicationCapacity to communicate appropriately and effectively in a variety of social situations, reading and using social cues with both peers and adults
Children; FADP, ARC Northland; University of WA –FASDPN.
FASD: A New Model 53
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"
FASD: A New Model 54
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
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: A New Model 57
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: A New Model 58
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: A New Model 59
FASD Wheel™ Case Study
FASD: A New Model 60
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.
FASD: A New Model for Achieving
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FASD: A New Model 61
FASD Wheel™ Case Study
FASD: A New Model 62
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: A New Model 63
FASD Wheel™ Case Study
FASD: A New Model 64
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: A New Model 65
FASD Wheel™ Case Study
FASD: A New Model 66
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.
FASD: A New Model for Achieving
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FASD: A New Model 67
FASD Wheel™ Case Study
FASD: A New Model 68
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.
FASD: A New Model 69
FASD Wheel™ Case Study
FASD: A New Model 70
FASD Wheel™ Case Study
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.
FASD: A New Model 71
FASD Wheel™ Case Study
FASD: A New Model 72
FASD Wheel™ Case Study
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.
FASD: A New Model for Achieving
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FASD: A New Model 73
FASD Wheel™ Case Study
FASD: A New Model 74
FASD Wheel™ Case Study
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: A New Model 75
FASD Wheel™ Case Study
FASD: A New Model 76
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: A New Model 77
FASD Wheel™ Case Study
FASD: A New Model 78
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.
FASD: A New Model for Achieving
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FASD: A New Model 79
FASD Wheel™ Case Study
FASD: A New Model 80
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
FASD: A New Model 81
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?
FASD: A New Model 82
Practical Application
FASD: A New Model 83
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)
FASD: A New Model 84
Good Frog – Bad Frog Re-Mix
When is she a good frog?
When is she a bad frog?
(Close your eyes and listen )…
FASD: A New Model for Achieving
Consistent and Creative Interventions that
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FASD: A New Model 85
Q & A
Questions & Answers
Don‘t forget to see the whole elephant
FASD: A New Model 86
More InformationMore on the wheel: www.FASDWheel.com
More on the FASD Elephant™ (plus info and podcasts!): www.FASDElephant.com