Running Header: Term Paper: Phase 3

Term Paper: Phase 3

Jodie Annis
Wayne State University
SW3810
Fi1274
July 20, 2014

Statement of the Problem

If children with reduced executive functioning (EF) due to Fetal Alcohol Syndrome are treated
with cognitive behavioral therapy will they have improved EF and other outcomes?

Fetal Alcohol Spectrum Disorders (FASD) are conditions that impact the lives of
thousands of children each year. These disorders are completely preventable, but once obtained
have lifelong implications for the children who suffer from them.
There are multiple disorders within FASD, the most severe being Fetal Alcohol
Syndrome (FAS). FAS includes abnormal facial features, growth problems, central nervous
problems, and can be confirmed by having the knowledge of alcohol consumption by the mother,
although this is not always necessary. FASD includes a group of conditions that can range from
mild to severe. These conditions can have a devastating impact on individuals physical,
behavior, and/or educational outcomes.
The Center for disease Control and Prevention, reports that approximately two out of
every 1,000 births is effected by Fetal Alcohol Syndrome (FAS) (Data, 2014). FASD has been
reported as high as 50 in every 1,000 births, making it more common than Autism. FASD is a
leading cause of preventable intellectual diseases affecting our children today (about FASD,
2014).
Taking care of children with a FASD requires a lifetime of medical intervention. These
medical costs add up to nine times that of a child without a FASD. The American government is
estimated to spend more than $6 billion annually on caring for those with a FASD (about FASD,
2014). A major deficit area, that requires costly treatment in children with FASD, is that of
Executive function.

Executive function (EF) is defined by Rasmussen as higher-order psychological

processes involved in goal-oriented behavior under conscious control (2005). EF includes many
cognitive functions that begin presenting around one year of age and continue through adulthood.
These functions include planning, flexible thinking, inhibition, working memory, and strategy
employment to name a few. Rasmussen found that in both FAS and FASD patients, all areas of
EF were affected. In the American population it is estimated that 30% of children suffer from EF
deficits. In the FAS and FASD population that percentage is thought to be significantly higher.
The population in the United States with a FASD is faced with many unnecessary trials.
Finding ways to help these children overcome or at least learn to live with these disabilities is
important to the success of our society.
Research Design
The study Neurocognitive Habilitation Therapy for Children With Fetal Alcohol
Spectrum Disorders: An Adaptation of the Alert Program by Wells, Chasnoff, Schmidt, Telford
& Schwartz looks at an intervention that may improve the outcomes for the sufferers of FASD
(2012). This research utilized a randomized control study. Both treatment and control groups
were selected from agencies working with children living in foster homes and from adoptive
families. Preceding the start and following the completion of therapy all participants were given
baseline assessments. To ensure internal validity the same tests were given each time.
Researchers attempted to control for internal validity through using randomization which seeks
to ensure that the control group is similar to the experimental group.

In addition, the therapists

frequently met to discuss methods being used during therapy times to ensure reliability of the
results.

This study was based on an isolated population group within the FAS community. Due
to none of the participants living with their biological parents the external validity of this
intervention is impacted. From this study it would not be fair to say that this intervention would
be effective for all FAS affected clients.
Sampling
The participants in this study ranged in age from six years to 11 year, 11 months. These
participants were all placed in out of home placements due to prenatal substance abuse or
continual substance abuse in the home. The children were tested to confirm FAS or Alcohol
Related Neurodevelopmental Disorder (ARND). From those confirmed 90 were invited to
participate and 78 families consented to participate in the study. Before placing the children in
groups each child was given a base-line research evaluation. After this, participants were
randomly placed in treatment and non-treatment control groups using simple random assignment.
Forty children were placed in the treatment group and 38 were placed in the control group. The
benefits to this form of selection is that the study has a high internal validity rate. One
disadvantage is that one group does not receive treatment, which may pose some ethical concern.
The research question posed is If children with reduced executive functioning (EF) due
to Fetal Alcohol Syndrome are treated with cognitive behavioral therapy will they have improved
EF and other outcomes? While this study addresses EF through cognitive behavior therapy it
leaves out a large portion of the FAS population. This omission lessens the external validity of
this research.

Measurement
Wells, Chasnoff, Schmidt, Telford & Schwartz focused on children diagnosed with FAS
or ARND living in foster or adoptive homes. Each childs health history was reviewed. Any
children with serious head injuries, lead poisoning or dysmorphic syndrome unrelated to FAS
were excluded from the study. All other participants were tested and given a diagnosis of FAS or
ARND. This diagnosis was based on three criteria: growth retardation, facial dysmorphology,
and central nervous system abnormalities. The testing began with a digital facial photographs to
assist in gaining accurate facial measurements. Following this all children were given a
neuropsychological evaluation to determine central nervous system function. Those with delays
in all three categories were diagnosed with FAS while the participants with confirmed alcohol
exposure without facial dysmorphology were diagnosed with ARND.
This study included parental involvement, therefore if the variables included children still
living with their biological family the outcomes may have changed. Parents who give birth to
FAS/ARND children may not be willing, or may not be capable of following through with the
new skills learned, and may have caused a marked decrease in the success of this treatment. In
addition to this, if the clients that had other closed head injuries, lead poisoning or facial
dysmorphology unrelated to FAS were included in the study the validity of the study may have
been compromised. Researchers may not have been able to determine what was causing
improvements or delays within this group.
Data Collection
Multiple baseline tests including, Behavior Rating Inventory of Executive Function
(BREIF), Roberts Apperception Test for Children (RATC), and the Wechsler Intelligence Scale

for Children-Third Edition (WISC-III) were given at the beginning and then repeated after 7
months. The BRIEF is an assessment that the primary care giver fills out regarding the executive
function behaviors at home and at school. The RATC is a test given to children measuring their
perception of common interpersonal situations. Finally the WISC-III was used to determine the
IQ of each child. The baseline data was then compared to the post data to determine the
effectiveness of neurocognitive habilitation therapy.
Overall the data collection methods were effective. Some areas of improvment existed.
Input from caregivers, as well as the children were taken. The BREIF was being used to
determine function at home and at school yet there was no mention of gaining any input from
school personnel. Also, there is the possibility of parental input not being accurate making it
important to have other sources complete this type of questionnaire to obtain accurate results.
Parents are also receiving training on how to parent FAS children, yet there is no measure of
their parenting skills. Without looking at their skills, while at the same time relying on their
answers regarding their children, it is hard to determine if the parents perspective is changing or
the child is changing. These areas may need to be addressed to improve the accuracy of future
studies.
If these adjustments were made in data collection it may give a more accurate picture of
the children receiving treatment. It is possible that the education provided to the parents
allowed them to view their children in a new way. This perspective change may have impacted
how they answered the questions on the follow-up assessment, thus improving their scores
without behavior change.

Ethics and Cultural Consideration

Wells, Chasnoff, Schmidt, Telford & Schwartz focus solely on the FAS/ARND
population that live in foster and adoptive placements, leaving out all of those still living with
their biological parents. This variable leaves a large portion of those effected by FAS and ARND
out of the study. To determine this interventions effectiveness on the total population it would be
necessary to repeat the study including all demographics effected by FAS and ARND.
To remain within ethical boundaries, this studys control group was not denied treatments
they were currently receiving, instead only new treatments were withheld. Also, during the
evaluations therapists were not aware if a participant was in the control group or therapeutic
group. This allowed for greater internal validity and a higher level of integrity within the
therapists.
Results and Implications
This study researches if Neurocognitive habilitation group therapy services would have a
positive effect on those who experience executive function problems due to FAS and ARND.
This focus directly addresses the question presented: If children with reduced executive
functioning (EF) due to Fetal Alcohol Syndrome are treated with cognitive behavioral therapy
will they have improved EF and other outcomes? Its concentration on the problem of
executive function through cognitive behavior therapy makes it very effective in addressing the
problem.
Neurocognitive habilitation therapy teaches children to self-identify problem areas and
implement strategies to overcome these deficit areas through building on existing areas of
strength. This therapy uses techniques that have been proven to be effective with victims of

traumatic brain injury. Wells, Chasnoff, Schmidt, Telford & Schwartz reported that children
in the intervention group demonstrated significant improvements in executive and emotional
functioning when compared with the control group (2012). Neurocognitive habilitation therapy
looks like a promising treatment for FAS/ARND sufferers in the future.
In order to implement this type of intervention it would be necessary to have several
professionals that function at a masters and doctorate level. To perform all of the interventions
therapists, physical therapists, and psychologists would be needed. It would be important to
have these professionals in order to effectively implement the intervention as well as measure the
success for each client.
Neurocognitive habilitation therapy is a new type of intervention for the FAS/ARND
population, therefore obtaining proper training at this time would be difficult. Without proper
training achieving competence may create ethical issues.
Conclusion
FAS/ARND children face a life long struggle of functioning at what society deems a
normal level. Their social, academic, and cognitive skills are lacking. This is a social issue that
needs to be give more focus. Neurocognitive habilitation therapy is showing signs of being a
viable treatment option in the future, but more research is needed. This populations disabilities
were not created by their own choices or by genetic disorders, but are instead completely
preventable. Our society needs to create a plan to surround these children and adults with the
support they need to live a meaningful life.

References
About FASD. (2014, May 30). FASD Center for Excellence. Retrieved June 4, 2014, from
http://fasdcenter.samhsa.gov/aboutUs/aboutFASD
Data & Statistics. (2014, May 23). Centers for Disease Control and Prevention. Retrieved June
5, 2014, from http://www.cdc.gov/ncbddd/fasd/data.html
Rasmussen, C. (2005). Executive Functioning and Working Memory in Fetal Alcohol Spectrum
Disorder. Alcoholism: Clinical And Experimental Research, 29(8), 1359-1367.
doi:10.1097/01.alc.0000175040.91007.d0
Richardson, R. (2009). Psychological & Educational Insight: A Closer Look At Fetal
Alcohol Spectrum Disorders And Executive Functioning. Exceptional Mental Health Provider
training manual. richardsonsconsulting.com/resource_center_art.html
Wells, A. M., Chasnoff, I. J., Schmidt, C. A., Telford, E., & Schwartz, L. D. (2012).
Neurocognitive habilitation therapy for children with fetal alcohol spectrum disorders: An
adaptation of the Alert Program. American Journal Of Occupational Therapy, 66(1),
24-34. doi:10.5014/ajot.2012.002691