3. How to support children living with Fetal Alcohol Spectrum Disorder (FASD)

What is this resource about?

This resource outlines the diverse neurocognitive challenges frequently faced by children living with FASD. It highlights some of the ways these differences may impact on children’s learning, behavioural and social development, and outlines the general principles for supporting children.

Who is this resource for?

This resource is for practitioners and other professionals working with parents of children with FASD, and workers who are supporting children with FASD. It is suited to child and family-facing practitioners, but may also be relevant for anyone working with parents who may be raising a child affected by FASD. The aim of this resource is to highlight the range of neurocognitive issues that children can face, and support practitioners to understand the possible impact of these difficulties on children’s lives.

Children who have been exposed to alcohol in utero are at increased risk of developing one or more of a range of physical, emotional, or cognitive difficulties. The range of reported changes in the physical, genetic and morphological aspects of development is extensive, and a complete description of these difficulties is outside the scope of this resource (see Popova et al., 2016; Weyrauch et al., 2017 for more detail).

The Australian Guidelines for the Diagnosis of FASD (2016) specifically identify ten domains of cognitive development that can be affected by prenatal alcohol exposure. The guidelines require significant levels of impairment in at least three of these domains to warrant a diagnosis of FASD.

Related: 1. What is Fetal Alcohol Spectrum Disorder (FASD)?

Brain development in children affected by FASD

The impact of FASD is unique to each child and depends on factors such as dosage, timing and duration of alcohol exposure. However, there appear to be some difficulties which are reasonably common; in particular, cognitive issues that impact on social relationships and educational achievement. While not all children will experience all of these difficulties, being aware of these challenges is an important first step in supporting children affected by FASD.

Potential neurocognitive impacts of FASD

The full range of cognitive difficulties experienced by children living with FASD is still being understood. While the extent and nature of difficulties that children might experience varies, some of the most common challenges are outlined below:

Impaired language skills

Children living with FASD often have significant language and communication difficulties. Language includes the ability to understand what others say (receptive language); to communicate to others (expressive language); and to use language socially (pragmatic language) (Carmichael Olson, King, & Jirikowic, 2008).

Children living with FASD frequently have both delayed language and language disorders. Language delay is typically associated with limited exposure to language rich environments, intellectual difficulties, chronic childhood ear infections, or other early adversities. A diagnosis of language delay might occur when a child’s communication skills are behind what would be expected for their age.

Language disorders involve difficulties in putting words together to convey meaning, in a socially appropriate context. A language disorder diagnosis might occur when a child has difficulty in producing and expressing speech, or in adapting and using language in different contexts and for different purposes. Children living with FASD also appear to have unusual language profiles – for example, caregivers report that children can appear talkative and engaged while at the same time having little actual understanding of the conversations they are taking part in.

Without support, children living with language difficulties are at risk of developing academic and social difficulties over time. This is because language plays such an important role in the processing of academic information, in understanding and following group activities and goals, and in conforming to ‘implicit’ social conventions (like taking turns, talking about the same topic, talking about common goals and interests, etc.).
There are a few strategies that can be helpful in supporting children living with FASD and language difficulties. These include taking steps to:

• simplify the language that a child needs to understand
• slow down the rate of communication
• explicitly teach social communication skills (e.g. taking turns in conversation).

The cognitive difficulties experienced by a child living with FASD will differ in nature and degree. These difficulties can make it harder for a child to successfully negotiate their learning and social environments, negatively impacting their development.

The impact of cognitive and sensory difficulties on each of these areas is outlined below:

Impact on new learning:
Cognitive, sensory and language differences can significantly impact on children’s capacity to engage with learning. In the learning environment, a child living with FASD can struggle with:

• managing frustrations in response to failure
• self-regulating to maintain optimal level of arousal and attention
• screening out visual, tactile and auditory distractions
• listening to and retaining classroom instructions
• keeping tasks in mind
• working out and completing steps of a task in sequence
• retaining what has been learned that day
• remembering information from one day to the next
• managing and directing attention as required
• transitioning seamlessly from task to task
• managing and regulating themselves in response to changes in expected routines or activities
• working together with their peers as part of a group activity
• learning from typical teaching techniques without additional support (e.g. short instructions, repeated instructions, visual supports)
• taking part in unstructured or ‘free play’ learning opportunities.

Cognitive difficulties can also affect social interactions and friendships. In social environments, a child living with FASD can struggle with:

• regulating strong emotions and being appropriately assertive
• remembering important social interactions and social information
• forward thinking to anticipate difficulties and problem solve solutions
• controlling behaviour and impulses in order to comply with social norms
• reflecting on social information by recalling past experiences
• reflecting on how a current experience relates to their past learning
• drawing on past social experiences to learn from mistakes and inform future decisions
• taking in and processing social information quickly
• responding quickly and acting on social information
• adjusting social behaviour in response to feedback from the social environment (e.g. peers)
• expressing themselves, their feelings and needs and understanding what others are communicating
• understanding and using social language conventions
• understanding humour, metaphors and sarcasm in social interactions.

By being aware of these differences, practitioners can make it easier for children living with FASD to experience positive and inclusive interactions within their broader social networks.

Children living with FASD are believed to do best in highly structured, simplified and predictable environments, in which expectations are clear. Most children will also require concrete, explicit teaching of social skills, communication skills and academic skills.

There are two broad approaches to supporting children living with FASD: universal and targeted accommodations.

Universal accommodations:

Universal accommodations are strategies that can be applied across all settings. They help children to succeed by creating an environment in which the child’s cognitive load, or sensory or language input is reduced.

Universal accommodations also create a supportive scaffold for a child’s development, by modifying the immediate environment to make it less overwhelming, and simplifying verbal interactions and instructions to make them more understandable. These universal approaches can act as a bridge, connecting the child with an otherwise fast-paced and potentially confusing world.

Universal approaches to helping children living with FASD include:

• modifying the environment to minimise sensory stimulation, remove known sensory triggers, and use visual reminders and visual aids to convey expectations
• modifying verbal interactions by shortening instructions, simplifying language, using lots of repetition, and supplementing instructions with visual cues and prompts; and
• supporting transitions of any kind. The redirection, focusing, and transitioning of attention can be supported by using stepped instructions; providing visual and verbal warnings about impending changes; providing clear task expectations, and modelling self-monitoring skills.

Related: Universal and inclusive accommodations to create FASD sensitive environments (PDF)

Targeted strategies:

Children living with FASD can also benefit from adopting a targeted approach to new learning. Specific, tailored approaches to instruction and learning can be helpful for children experiencing memory and attention problems. Although the evidence base for these approaches is still being developed, caregivers report that specific and tailored teaching methods can work well for children living with FASD.

Tailored learning approaches involve:

• starting with the simplest form of the target skill and building from there
• breaking complex skills into component skills and skill sequences, and teaching each in order
• repetition and overlearning of each skill in order to embed skills.

When deciding where to begin in teaching new skills, it is important to keep in mind a child’s developmental age, rather than their chronological age, as the two can be quite different. Specific and targeted teaching methods can build a child’s sense of competence by explicitly teaching skills which might be delayed, and which may not be picked up otherwise.

Related: Tailored teaching strategies for supporting children living with FASD (PDF)

Children who are affected by prenatal alcohol exposure may experience one or more significant neurocognitive difficulties in one or more areas of development. At present, there does not appear to be any way to reverse the impact of prenatal alcohol exposure on the developing fetus (Australian Medical Association, 2016).

Currently, the best way to support children is to create a better ‘fit’ between a child’s ability and their social and learning environment; thereby minimising the risk of educational disengagement, social and peer relationship difficulties, and behavioural and emotional concerns.

There are two main approaches to this:

1. applying universal strategies that modify the child’s environment to create a better ‘fit’ for the child and make the environment and expectations more manageable.
2. applying targeted approaches to learning, supporting the child to build the skills necessary to strengthen their executive functioning and counteract the neurological challenges they experience.

Practitioners can play a key role in supporting caregivers and teachers to adopt both universal and targeted approaches. The evidence base for social learning and pharmacological interventions for children living with FASD is still growing (McLean & McDougall, 2014; McLean, McDougall & Russell, 2014; Peadon, Rhys-Jones, Bower, Elliot, 2009; Premji et al., 2007). In the meantime, the approaches outlined in this resource can help to support children and may minimise the impact of FASD on children’s development.

References

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