Psychology of Learning Article Reviews

These article reviews cover various psychology of learning topics: behavioural analytic psychology, cognitive psychology, socio-cultural psychology, Indigenous psychology, developmental psychology, and gestalt psychology.

Westmount School YouTube Channel

Our school has a YouTube channel for announcements. During this “learning-at-home” phase, teachers are using the channel to read books and continue to update our student body. Check out this reading of “There is a Bird On Your Head” by Mo Willems. Remember to subscribe to our channel!

Stay safe, stay home! We miss you, kiddos!

Tell Them Tuesday

February 11th, 2020

Dear Greg Lawrence, Lyle Stewart, and Gordon Wyant of the Saskatchewan Party,

Today, as we vote on sanctions, I reflect on the conditions within our classrooms in Saskatchewan. I think about the way things are and how far that is from how they should be. Mostly, I think about how much I love my job and care about each and every student that I’ve had the privilege to teach. I worry daily that I am not doing enough for them, but with the current conditions there is no way I ever could be. 

This is not about money – even though educators should care that our salaries are not increasing at the same rate as the cost of living, thus reducing our spending power. This isn’t about the ploy to give us $1,500 of our own surplus health plan money that would then be taxed. It’s a little bit about not covering our 1.5% wage increase last contract and forcing divisions to cover the cost, leaving 24 out of 26 divisions with a deficit budget. But that’s only because this decision ultimately resulted in less teachers and educational assistants in our classrooms. We’ve accepted 0% before. We didn’t become teachers for the money. We are merely asking for decent working conditions. We want to work in an environment where we do not feel overwhelmed, understaffed, and muzzled. We want to work in a system that allows us to meet the needs of all our learners. We want each student to achieve to the best of their abilities. We shouldn’t have to ask for this and we certainly shouldn’t have to fight for it.

I dream of working in a learning environment that I would want for my nephew, own children, friend’s children, your children, and all the children in Saskatchewan. That dream starts with a discussion around classroom composition. We need a contract which ensures that the kids who need support get it, in turn helping all children have the learning environment and supports they need to succeed. Something so crucial to the success of our province should be on the bargaining table, yet the Saskatchewan Party refuses to discuss it. We don’t need another committee to tell us that there is no money (read: education is not a priority). If we want a healthy Saskatchewan, education should be high on the list. We don’t need another committee to tell us what we already know: chronic underfunding has left education in a dire state.

Education Minister Gordon Wyant said himself, “our students need our teachers in the classroom.” I couldn’t agree more. Yet, even though enrollment has increased by 20,000 with 6,000 additional English as Additional Language (EAL) learners, less than 200 classroom teachers have been hired and only 21 EAL teachers. We lack educational psychologists, educational assistants, counsellors, speech therapists, and occupational therapists in our schools. While some divisions lack these roles in terms of numbers, others do not have the means to hire these professionals altogether, leaving students with unmet needs that teachers are trying to fill with no additional time or resources.

Imagine a split class of 30 students. Some are First Nations with relationships that we need to mend from previous injustices. Others are EAL with past trauma and limited English proficiency. There are a handful of students on Inclusive Intervention Plans (IIPs) who may or may not have diagnoses – anything from Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), Learning Disabilities (LDs), Oppositional Defiance Disorder (ODD), etc. Others are struggling but are waiting to be assessed, and thus they are not being supported by outside agencies or being represented on intensive support lists. Some have been assessed but there are no available school professionals or outside agencies to provide support. A couple of students have behavioral plans and violent outbursts that evacuate the classroom and compromise staff and student safety. We have students who are homeless and haven’t had lunch for days. We have students with Child Protection Services (CPS) involvement, those on the run from abuse, and those with mental health and addictions in their immediate lives. There are students with medical needs that need to be monitored. We have students who threaten to bring weapons to school and others who we worry about sending home at the end of the day. There are the students who rarely attend. Academically, there can be up to 8 levels of reading, math, and writing in one room. There is no educational assistant in this room and minimal outside agency support. It’s just one teacher, being asked to manage it all.

This isn’t fictitious – this is the new norm.  Do the math: teaching 30 students in a 7-hour day equates to about 14 minutes with each child. Trying to meet these complex needs within that time frame is mindboggling, without even planning for the curriculum. Between the extra-curricular activities, trying to teach all outcomes to all children despite the aforementioned concerns, rewarding positive behavior, deescalating violent outbursts, creating classroom materials, marking assignments, implementing differentiated instruction and adaptations for all three tiers, lesson planning and goal setting, following multiple behavior supports plans (often with conflicting strategies), documenting our every move, taking data for behavioral support plans, assessing each and every outcome and indicator, lunch duty, increasing parent engagement, and so on, you start to realize the absurdity of what we expect our teachers to do. 

I wouldn’t be surprised if you stopped reading. I also feel like it’s too much. It’s no wonder that close to 50% of teachers quit within the first five years. Enrollment is up, inflation is up, but why aren’t our priorities keeping up? We can’t keep guilting teachers to do more and be more with less. In this system, we will never be enough. I became a teacher because I believe in inclusion, but our funding model is leaving everyone behind.

You have the opportunity to change the trajectory of education in Saskatchewan. The financial decisions you make will impact the future of this province. We need a stable fiscal plan for education and that includes discussing classroom composition and making our students the top priority, as they should be. Yes, we need responsible spending as taxpayers work hard for their money. But prioritizing education is money well spent. The government needs to be held accountable for student success and the standard of education in this province. Teachers are burning out and that should scare us all. Teaching conditions are the learning conditions of our students and our students are the future of this province!

Sincerely,

Kourtney Gorham, B.Ed.

Educational Psychology Presentations

Presentations by Kourtney Gorham at the University of Regina

ED 800 Presentation Fall 2018

Best Practices: Fetal Alcohol Spectrum Disorder (FASD)

By: Kourtney J. Gorham at The University of Regina for EPSY 821 – Aptitude and Achievement Analysis (Instructor Rori Lee)

Best Practices: Fetal Alcohol Spectrum Disorder (FASD)

Introduction: FASD Definition, Symptoms, and Prevalence

According to the FASD Network of Saskatchewan (2017) and the Canadian FASD Research Network (2019), Fetal Alcohol Spectrum Disorder (FASD) is a lifelong disability caused by prenatal alcohol exposure (PAE) that can impact an individual’s behavioral, cognitive, physical, and sensory domains. FASD has both neurocognitive and neurobehavioral implications, as PAE damages the Central Nervous System (CNS) in the developing fetus (Brown, Connor, Adler, and Langton, 2012; Nash & Davies, 2017; Popova, Lange, Burd, & Rehm, 2015). While specific impairments may not be realized until later in life when environmental demands increase, challenges with fine and gross motor skills, daily living skills, physical and mental health, learning, memory, executive functioning, receptive communication, social skills, and self-regulation may occur (Brown et al., 2012; CanFASD, 2019; FASD Network, 2017; Kully-Martens et al., 2018). However, each individual will experience different strengths and challenges and thus, requires individualized supports to target their unique areas of need.

FASD often goes undiagnosed due to stigma, lack of awareness, and the fact that it is an invisible disability as many individuals have no physical markings (FASD Network, 2017; Nash & Davies, 2017). Furthermore, FASD may be misdiagnosed as it commonly co-occurs with Attention Deficit Hyperactive Disorder (ADHD) – 40-90% of cases (Glass et al., 2017), Autism Spectrum Disorder (ASD), Bipolar Disorder (BD), Major Depressive Disorder (MDD), Intellectual Developmental Disorder (IDD), Oppositional Defiance Disorder (ODD), Reactive Attachment Disorder (RAD), Specific Learning Disability (SLD) – 17-35% of cases (Glass et al., 2017), and other sensory and trauma-related concerns (FASD Network, 2017; Nash & Davies, 2017). This is problematic because appropriate supports may not be in place without appropriate diagnosis.

FASD impacts individuals from all socioeconomic classes and ethnic groups and is especially apparent in cultures where alcohol is culturally accepted. The FASD Support Network (2017) notes that, “in Saskatchewan, it is believed that 1 in 100 people may be affected by FASD” (p. 4). CanFASD (2019) reports that “4% or 1.4 million people in Canada have FASD” (n.p.). These high rates may occur because approximately half of all pregnancies are unplanned (Nash & Davies, 2017) and there is no known safe amount or time to consume alcohol when pregnant (CanFASD, 2019; FASD Network, 2017; Osterman, 2011; Zizzo & Racine, 2017), including during the first month when individuals may not be aware of their pregnancy.  Statistics show that, on average, 90% of women abstain from drinking alcohol during pregnancy (Kully-Martins et al., 2018; Nash & Davies, 2017; Singal et al., 2017). However, social inequalities, lack of awareness, and previous addictions may contribute to continued use in some cases (Migliorini et al., 2015), making PAE a societal reality.

Overall fetal development is impacted by the quantity and timing of alcohol exposure, maternal metabolism rate, and the overall nutritional status of the mother (Brown et al., 2012; Kalberg & Buckley, 2007). Thus, not all individuals who have been prenatally exposed to alcohol will be diagnosed with FASD and presentations vary among those with the diagnosis (Brown et al., 2012; Kalberg & Buckley, 2007). Individual profiles may differ because neuroanatomical changes in the brain interact with the person’s environment to produce behaviors, particularly social deficits (Kully-Martens, Denys, Treit, Tamana, & Rasmussen, 2012). Within the behavioral domain, dysmaturity, issues interpreting social cues, and low self-esteem may occur (FASD Network, 2017; Kully-Martens et al., 2012). Brown et al. (2012) note that individuals with FASD are susceptible to peer pressure due to impulsivity, executive functioning deficits, and issues making, selecting, and retaining positive friendships. Cognitive impairments may include short attention spans, failure to learn from mistakes, and struggling to sequence behavior to reach a goal (executive functioning) (FASD Network, 2017; Kalberg & Buckley, 2007). Within the physical and sensory domains, poor balance and coordination, sensory processing concerns, and failure to meet height and weight developmental milestones may occur (FASD Network, 2017). These symptoms, and many more, can lead to secondary challenges such as unemployment, addictions, run-ins with the law, underachievement, difficulty learning advanced concepts, and school-drop out (FASD Network, 2017; Popova et al., 2015). In fact, individuals with FASD are 19 times more likely to go to jail (Popova et al., 2015), this being amplified if their needs are unmet, early diagnosis did not occur, and environmental concerns are present (Brown et al., 2012). While there is no cure for FASD, treatment to reduce secondary concerns is crucial.

Diagnosing FASD

 A multidisciplinary team of specialists is required to make a FASD diagnosis (Birch, Carpenter, March, Mcclung, & Doll, 2016; Cook et al., 2016; FASD Network, 2017). This team may include a specially trained physician, an educational and/or clinical psychologist or social worker, a speech language pathologist, an occupational therapist, a psychiatrist, and/or a pediatrician (FASD Network, 2017). Furthermore, once a diagnosis is made, treatment planning may include referrals to other specialized service providers. Brown et al. (2012) recommend a minimum of three professionals including a neuropsychologist to do the comprehensive testing, a medical doctor to conduct a physical examination, and a psychologist to administer psychological assessments, observe the child in multiple environments if possible, and interview and integrate information from all applicable sources, such as caregivers and birth records (Coons-Harding, Flannigan, Burns, Rajani, & Symens, 2019; Kalberg & Buckley, 2007; Sattler, 2014).

A FASD diagnosis requires three significant deficits at least 1 standard deviation (SD) below the mean in at least three neurocognitive domains and/or global IQ deficits (Brown, Connor, & Adler, 2012). Typically impairments must be below the third percentile (Coons-Harding et al., 2019). In addition to this, facial features, growth delays, and CNS functional, structural, and neurological damage may be apparent (Brown et al., 2012; Walker, Edwards, & Herrington, 2016). The FASD Network (2017) describes three diagnoses on the FASD spectrum: FASD with sentinel facial findings, FASD without sentinel facial findings, and at risk for neurodevelopmental disorder and FASD. To diagnosis FASD with sentinel facial findings there must be three facial features and three domains of impairment but PAE does not need to be confirmed (FASD Network, 2017). The facial features include “a thin upper lip, short palpebral fissure (the opening between eye lids), and smooth/flattened philtrum (the groove between the nose and lip)” (FASD Network, 2017, p. 6). In the second type, three domains of impairment remain but facial features are not required. In the absence of facial features, PAE must be confirmed (FASD Network, 2017). The at risk designation involves three facial features or PAE confirmed and a clinical concern about development (FASD Network, 2017).

Unfortunately, there are many barriers to receiving a diagnosis such as long waitlists, lack of service providers for all age groups, social inequalities such as transportation or rural access difficulties, lack of education and understanding, and persisting stigmatization of mothers (Chamberlain, Reid, Warner, Shelton, & Dawe, 2016; FASD Network, 2017).  In Saskatchewan we currently do not have a specially trained physician to identify short palpebral fissures, making FASD with sentinel facial findings hard to diagnose (FASD Network, 2017). For children, diagnosis and assessment services can be acquired through Child and Youth Services centers in Prince Albert, Saskatoon, and Regina. Adults can be referred to Child and Youth Services in Regina, Dr. Gerald Block in northern and central Saskatchewan, or the Saskatoon Genetics/Teratology Clinic at the Royal University Hospital in Saskatoon (Government of Saskatchewan, 2019). Supports, with or without diagnosis, can be obtained from the FASD Support Network of Saskatchewan and Raising Hope/Regina Street Worker’s Advocacy Program. Furthermore, caregivers and educators can consult the Best Practices for Serving Individuals with Complex Needs: Guide and Evaluation Toolkit (2018) by the Alberta Clinical and Community-Based Evaluation and Research Team and the FASD Prevention Framework (2014) from the Saskatchewan Prevention Institute.

FASD Diagnostic Tools

A variety of tools are used to asses FASD: the FASD Behavioral Mapping Tool to assess dysmaturity (FASD Network, 2017); the Fetal Alcohol Behavioral Scale that screens for 36 behaviors under the communication, emotional, social skills, academic, motor skills, and functional domains (Brown et al., 2012); and the FASD 4-Digit Diagnostic Code to assess the key diagnostic features (Walker et al., 2016). In addition, a battery of psychological tests and observations are used to look at domain-specific impairments in one or more of the following areas: motor skills, cognition, language, academic achievement, memory (verbal, auditory, and spatial), attention, executive functioning, affect recognition, and adaptive behavior (social skills and communication) (Brown et al., 2012; Kalberg & Buckley, 2007). Kalberg and Buckley (2007) note that an individual’s overall IQ score matters less than their ability to function within their environment, making a complete battery of assessments and observations essential.

Domain-specific assessments vary but should follow the Canadian FASD Research Network’s 2015 guidelines, with direct measures being preferred (CanFASD, 2019; Coons-Harding et al., 2019). Coons-Harding et al. (2019) surveyed 23 FASD clinics in Alberta to determine the comprehensive battery of neuropsychological tests that were being used. In some instances, assessments that were not recommended in the 2015 guidelines and older test editions were used. However, the following list includes the best practice measures that were used under each domain, with the first assessment in the list being used more frequently than the last (Coons-Harding et al., 2019, p. 45-9):

  1. Motor Skills Domain: Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition; Beery-Buktenica Developmental Test of Visual-Motor Integration – 6th Edition; Grooved Pegboard/Purdue Pegboard Test; Finger Tapping/Oscillation Test; Hand Dynamometer/Hand Grip Strength Test; Peabody Developmental Motor Scales – 2nd Edition; Miller Function and Participation Scales and Movement Assessment Battery for Children – 2nd Edition for caregiver interviews
  2. Cognitive Domain: Wechsler Adult Intelligence Scale – 3rd Edition; Wechsler Intelligence Scale for Children – 5th Edition; and Wechsler Preschool and Primary Scale of Intelligence – 4th Edition  
  3. Language Domain: Peabody Picture Vocabulary Test – 4th Edition; Clinical Evaluation of Language Fundamentals – 5th Edition; Test of Narrative Language – 2nd Edition; Expressive Vocabulary Test – 2nd Edition; Preschool Language Scales – 5th Edition; Perceptive-Expressive Emergent Language Test – 3rd Edition; Renfrew Bus Story; and language samples
  4. Academic Achievement Domain: Wechsler Individual Achievement Test – 3rd Edition; Woodcock Johnson Tests of Achievement – 4th Edition; Wide Range Achievement Test – 4th Edition
  5. Memory Domain: California Verbal Learning Test – 2nd Edition; Rey Complex Figure Test and Recognition Trial; Wide Range Assessment of Memory and Learning – 2nd Edition; NEPSY-II Subtests; Wechsler Memory Scale Revised – 4th Edition; Children’s Memory Scale
  6. Attention Domain: Connors – 3rd Edition and Adult ADHD Rating Scales; Behavior Assessment System for Children – 3rd Edition; Connors Continuous Performance Test –3rd Editions; and observations, anecdotal evidence, and reports from educators/caregivers
  7. Executive Function Domains: Behavior Rating Inventory of Executive Functioning – 2nd Edition; NEPSY-11; Delis-Kaplan Executive Function System; Test of Problem Solving – 2nd Edition (Adolescent) and 3rd Edition (Children); Wechsler Working Memory Scales; Wisconsin Card Sort Task; Behavior Assessment System for Children – 3rd Edition; Rey Complex Figure Test/Rey-Osterreich Complex Figure
  8. Affect Recognition Domain: Behavior Assessment System for Children – 3rd Edition; Beck Depression Inventory – 2nd Edition; Beck Anxiety Inventory; and previous/current diagnosis
  9. Adaptive Behavior (Social Skills and Communication) Domain: Adaptive Behavior Assessment System – 3rd Edition; Social Language Development Test; Vineland Adaptive Behavior Scales – 3rd Edition

FASD Best Practice Supports                                                                            

Supports for FASD generally fall under the best practice realm, as many of the strategies are general or have not been researched enough to be deemed evidence-based. This is further complicated by misdiagnosis, underdiagnoses, comorbid conditions, resource gaps for certain ages, and the variability of FASD presentations (FASD Network, 2017; Griffin & Copeland, 2018; Olson, 2016). The Alberta Clinical and Community-Based Evaluation and Research Team outlined supports with expert consensus, good evidence, moderate evidence, and some evidence in Practices for Serving Individuals with Complex Needs: Guide and Evaluation Toolkit (2018). Strategies with expert consensus included transition-focused supports and future planning, staff education, trauma supports, interpersonal skills, age-appropriate services, consistency and structure, Functional Behavior Assessments (FBA), preventative medical and mental health care, supported recreational activities, managing sexually exploitative situations and risky behaviors, person-centered employment, financial aid and access support, support with the justice system, and individualization. Supports with good evidence included early diagnosis, focusing on caregiver wellbeing, stable home environments, consistency, collaboration, responsiveness, and proactivity. Supporting sensory processing, utilizing unique learning profiles, parent-assisted adaptive functioning training and other educational resources had moderate evidence. Individual support, agency collaboration, strengths-based approaches, and secure and safe housing had some evidence (Pei, Tremblay, Poth, Hassar, & Ricioppo, 2018). Similarly, the FASD Network (2017) recommends general strategies in the areas of memory, confabulation, cause and effect, time management, transitions, ownership, impulse control, social skills, sensory, and sleep. Examples of strategies include repeating instructions in multiple ways, increasing time, and utilizing visuals (memory); probing only if it is a dangerous story and utilizing social stories (confabulation); utilizing positive reinforcement, visual reminders of expectations, and decision mapping (cause and effect); implementing timers, calendars, schedules, and predictable routines (time management); utilizing forewarning, prior practice. and visual schedules (transitions); practicing borrowing items and labelling personal belongings (ownership); implementing role-playing scripts, perspective taking, and supervision as needed (impulse control); modelling behavior, providing mentorship that builds off strengths, and setting developmentally appropriate expectations (social skills); reducing distractions, utilizing adaptive seating, and movement breaks (sensory); and implementing a calming sleep routine that may include doctor recommendations (sleep) (FASD Network, 2017). While the supports are general, they should be selected based on individual needs and strengths.

Specific programs for FASD have been created, however often with limited research or acceptable norm groups. The Children’s Friendship Training (CFT) program was created by the CDC Cooperative Research Group and combines child friendship training with parental education. Children learn how to enter play, interact with peers, and resolve conflicts during 12 weekly 90-minute sessions. Techniques such as role play, homework assignments, and caregiver play coaching are used (Brown et al., 2012). Olson (2016) reported immediate positive “effects on social knowledge and skills, and problem behavior” (p. 1819) and Brown et al. (2012) noted that these positive gains were maintained three months later.

The Math Interactive Learning Experience (MILE) also has been shown to be effective with results lasting after six months (Kable, Taddeo, Strickland, & Coles, 2015; Kully-Martens et al., 2017). It was created by Kable in 2007 and piloted to 61 children ages three to ten in Georgia. In the program, students receive six weeks of one-on-one math instruction that is individualized based on their baseline data and includes interactive and physical exploration of objects, slower instruction, immediate feedback on errors, and metacognition techniques for problem solving through the Plan-Do-Review model or Focus-Act-Reflect (FAR) mnemonic. Parents receive six weeks of training. In Kable et al.’s (2015) self-report study, students had learned twelve new math concepts vs. three in the control group after two months but it was a small sample size and the parental piece may not have had any impact. In a Canadian study with 28 children ages four to ten, those who were older with confirmed PAE but no FASD diagnosis, and lower IQs made greater gains with MILE (Kully-Martens et al., 2018).

Additional programs are available for specific areas of need. Caribbean Quest is a computer program that targets attention and working memory and MacSween et al. (2015) note that the program led to significant improvements with auditory, visual, and working memory. The GoFar program aims to improve self-regulation and adaptive skills through computerized games, parent training, and the FAR mnemonic (Kable, Taddeo, Strickland, & Coles, 2016). The program occurs over ten weeks with phase one focusing on learning the FAR technique and phase two focusing on application of the strategy. It has online and in-person parent training options (Kable et al., 2016). However, the sample size was small and little research about the effectiveness is available.  Parents Under Pressure (PuP) focuses on self-regulation and mindfulness through the child-parent relationship (Reid et al., 2017). This program has preliminary support because there was a small sample size and issues with accurately measuring growth. It was built on the foundation “that self-regulation underpins adaptive functioning” (Reid et al., 2017, p. 46). Project Step Up promotes parental education and harm-reduction for youths with FASD using substances. It has satisfactory results for those with IQs over 70 but success may actually be attributed to supportive home environments (O’Connor, Quattlebaum, Castaneda, & Dipple, 2016; Olson, 2016). Step-by-Step is a one-on-one mentorship program for parents affected by FASD. It assists individuals with socioeconomic disadvantages but little research is available (Denys, Rasmussen, & Henneveld, 2011). While there are many available programs, continued research is needed to determine which programs can be considered evidence-based strategies.

 Conclusion

While there is no cure for FASD, targeted intervention and remediation of secondary concerns is promising. Medications are sometimes used to target comorbid conditions (Brown et al., 2012; Nash & Davies, 2017) but additional research is needed as stimulant medications have controversial results and may increase heart problems and seizures in this population (Brown et al., 2012) . Pei et al. (2017) note that recommendations made most to least are:  “education, medical, anticipatory guidance, accommodations, family support, mental health, developmental therapy, social services/child welfare, community/social/leisure programs, safety, reassessment, and other” (p. 176). However, they found that recommendations may be based on comorbid disorders or availability in the community rather than individualized need. Brown et al. (2012) recommend that no matter what program or strategy is used, the focus should be on replacing maladaptive behaviors. Additional research on strategies and programs for individuals with FASD will help determine evidence-based supports. Providing the subsequent supports and services to all those impacted by FASD is paramount in remediating lifelong secondary concerns and helping individuals be as successful as they can be.

Works Referenced

Birch, S., Carpenter, H., Marsh, A., Mcclung, K., & Doll, J. (2016). The knowledge of rehabilitation professionals concerning fetal alcohol spectrum disorders. Occupational Therapy In Health Care, 30(1), 69-79.

Brown, N., Connor, P., Adler, R., & Langton, C. (2012). Conduct-disordered adolescents with fetal alcohol spectrum disorder: Intervention in secure treatment settings. Criminal Justice and Behavior, 39(6), 770-793.

CanFASD: Canada FASD Research Network (2019). Diagnosis.Retrieved from: https://canfasd.ca/topics/diagnosis/

Chamberlain, K., Reid, N., Warner, J., Shelton, D., & Dawe, S. (2017). A qualitative evaluation of caregivers’ experiences, understanding and outcomes following diagnosis of FASD. Research in Developmental Disabilities, 63(C), 99-106.

Cook, J. L., Green, C. R., Lilley, C. M., Anderson, S. M., Baldwin, M. E., Chudley, A. E.,… Rosales, T. (2016). Fetal alcohol spectrum disorder: A guideline for diagnosis across the lifespan. Canada Fetal Alcohol Spectrum Disorder Research Network, 188(3), 191-7.  

Coons-Harding, K., Flannigan, K., Burns, C., Rajani, H., & Symens, B. (2019). Assessing for fetal alcohol spectrum disorder: A survey of assessment measures used in Alberta, Canada. Journal of Population Therapeutics and Clinical Pharmacology, 26(1), 39-55.

Denys, K., Rasmussen, C., & Henneveld, D. (2011). The effectiveness of a community-based intervention for parents with FASD. Community Mental Health Journal, 47(2), 209-219.

FASD Network of Saskatchewan Inc. (2017). Fetal alcohol spectrum disorder: A guide to awareness and understanding.

Glass, L., Moore, E., Akshoomoff, N., Jones, K., Riley, E., & Mattson, S. (2017). Academic difficulties in children with prenatal alcohol exposure: Presence, profile, and neural correlates. Alcoholism: Clinical and Experimental Research, 41(5), 1024-1034.

Government of Saskatchewan (2019). Fetal alcohol spectrum disorder services. Retrieved from: https://www.saskatchewan.ca/residents/health/accessing-health-care-services/health-services-for-people-with-disabilities/fetal-alcohol-spectrum-disorder-services#fasd-diagnosis-and-assessment-services

Griffin, M., & Copeland, S. (2018). Effects of a self-management intervention to improve behaviors of a child with fetal alcohol spectrum disorder. Education and Training in Autism and Developmental Disabilities, 53(4), 405-414.

Kable, J., Taddeo, E., Strickland, D., & Coles, C. (2016). Improving FASD children’s self-regulation: Piloting phase 1 of the GoFAR intervention. Child & Family Behavior Therapy, 38(2), 124-141.

Kable, J. A., Taddeo, E., Strickland, D., & Coles, C. (2015). Community translation of the math interactive learning experience program for children with FASD.  Research in Developmental Disabilities, 39, 1-11.

Kalberg, W., & Buckley, D. (2007). FASD: What types of intervention and rehabilitation are useful? Neuroscience and Biobehavioral Reviews, 31(2), 278-285.

Kully‐Martens, K., Denys, K., Treit, S., Tamana, S., & Rasmussen, C. (2012). A review of social skills deficits in individuals with fetal alcohol spectrum disorders and prenatal alcohol exposure: Profiles, mechanisms, and interventions. Alcoholism: Clinical and Experimental Research, 36(4), 568-576.

Kully-Martens, K., Pei, J., Kable, J., Coles, C., Andrew, G., & Rasmussen, C. (2018). Mathematics intervention for children with fetal alcohol spectrum disorder: A replication and extension of the math interactive learning experience (MILE) program. Research in Developmental Disabilities, 78, 55-65.

Macsween, J., Kerns, K. A., Macoun, S., Pei, J., Hutchinson, M., Rasmussen, C., & Bartle, D. (2015). Investigating the efficacy of computerized cognitive intervention for children with FASD and ASD. International Journal of Developmental Neuroscience, 47, 13.

Migliorini, R., Moore, E., Glass, L., Infante, M., Tapert, S., Jones, K.,… Riley, E. (2015). Anterior cingulate cortex surface area relates to behavioral inhibition in adolescents with and without heavy prenatal alcohol exposure. Behavioural Brain Research, 292, 26-35.

Nash, A., & Davies, L. (2017). Fetal alcohol spectrum disorders: What pediatric providers need to know. Journal of Pediatric Health Care, 31(5), 594-60.

O’Connor, M., Quattlebaum, J., Castañeda, M., & Dipple, K. (2016). Alcohol intervention for adolescents with fetal alcohol spectrum disorders: Project step up, a treatment development study. Alcoholism: Clinical and Experimental Research, 40(8), 1744-1751.

Olson, H. (2016). A renewed call to action: The need for systematic research on interventions for FASD. Alcoholism: Clinical and Experimental Research, 40(9), 1817-1821.

Osterman, R. (2011). Decreasing women’s alcohol use during pregnancy. Alcoholism Treatment Quarterly, 29(4), 436-452.

Pei, J., Baugh, L., Andrew, G., & Rasmussen, C. (2017). Intervention recommendations and subsequent access to services following clinical assessment for fetal alcohol spectrum disorders. Research in Developmental Disabilities, 60, 176-186.

Pei, J., Tremblay, M., Poth, C., Hassar, B. E., & Ricioppo, S. (2018). Best Practices for Serving Individuals with Complex Needs: Guide and Evaluation Toolkit. PolicyWise for Children and Families in collaboration with the University of Alberta. Retrieved from: https://canfasd.ca/wp-content/uploads/sites/35/2018/09/Best-Practices_June12018.pdf

Popova, S., Lange, S., Burd, L., & Rehm, J. (2015). Cost attributable to fetal alcohol spectrum disorder in the Canadian correctional system. International Journal of Law and Psychiatry, 41, 76.

Reid, N., Dawe, S., Harnett, P., Shelton, D., Hutton, L., & O’Callaghan, F. (2017). Feasibility study of a family-focused intervention to improve outcomes for children with FASD. Research in Developmental Disabilities, 67, 34-46.

Saskatchewan Prevention Institute. Fetal alcohol spectrum disorder (FASD) prevention framework (2014). Government of Saskatchewan.

Sattler, J. (2014). 6th Ed. Foundations of behavioral, social, and clinical assessment of children. La Mesa, California: Jerome M. Sattler, Publishers, Inc.

Singal, D., Brownell, M., Chateau, D., Hanlon-Dearman, A., Longstaffe, S., & Roos, L. (2017). The psychiatric morbidity of women who give birth to children with fetal alcohol spectrum disorder (FASD): Results of the Manitoba mothers and FASD study. The Canadian Journal of Psychiatry, 62(8), 531-542.

Walker, D. S., Edwards, W. E., & Herrington, C. (2016). Fetal alcohol spectrum disorders: Prevention, identification, and intervention. The Nurse Practitioner, 41(8), 28-34.

Zizzo, N., & Racine, E. (2017). Ethical challenges in FASD prevention: Scientific uncertainty, stigma, and respect for women’s autonomy. Canadian Journal of Public Health, 108(4), 414-417.

Anatomical and Physiological Changes to the Brain Due to Prenatal Alcohol Exposure (PAE)

By: Kourtney J. Gorham at The University of Regina for EPSY 836 – Neuropsychology  (Instructor Louise Burridge)

Anatomical and Physiological Changes to the Brain Due to Prenatal Alcohol Exposure (PAE)

Introduction

Alcohol is a teratogen that has detrimental effects on the developing fetus, often causing anatomical and physiological changes to the brain. When a pregnant mother consumes alcohol, it enters through the placenta and impacts fetal development through cellular and structural impairments (Brown, Connor, Adler, & Langton, 2012; Lebel, Roussotte, & Sowell, 2011). According to Nash and Davies (2017), the fetus’s blood-alcohol level matches the mother’s blood-alcohol level after an hour or two. However, due to reuptake of amniotic fluid, the blood-alcohol level can remain high for longer (Nash & Davies, 2017). Additional factors such as the mother’s metabolism and health, the amount of alcohol consumed, the frequency of consumption, and the point in fetal development when the insult occurred all contribute to overall fetal health (Brown et al., 2012; Kolb, Whishaw, & Teskey, 2019; Nash & Davies, 2017). It is generally agreed that the first trimester – particularly during the second through eighth weeks when the brain structures start to form and DNA synthesis occurs – is a critical time period when the effects of alcohol can be quite damaging (Brown et al., 2012; Kolb et al., 2019; Saskatchewan Prevention Institute, n.d.). For instance, Lebel et al. (2011) found that facial dysmorphology likely occurs when alcohol is consumed during the third and fourth weeks of fetal development. However, there is no safe time or safe level of alcohol to consume during pregnancy (CanFASD, 2019; FASD Network of Saskatchewan [FASD Network], 2017; Osterman, 2011; Saskatchewan Prevention Institute, n.d.; Zizzo & Racine, 2017) and even one drink per day has been found to lower IQ levels (Nash & Davies, 2017). For researchers, caregivers, educators, healthcare providers, speech pathologists, occupational therapists, and psychologists alike, knowledge about the anatomical and physiological changes to the brain due to prenatal alcohol exposure (PAE) is crucial for implementing appropriate supports and interventions.

For four decades we have known about the harmful effects of alcohol on the developing fetus (Glass et al., 2017), yet insults still occur. PAE can lead to a diagnosis of Fetal Alcohol Spectrum Disorder (FASD) – a lifelong disability that can impact an individual’s behavioral, cognitive, physical, and sensory domains (CanFASD, 2019; FASD Network, 2017). FASD has both neurocognitive and neurobehavioral implications, as PAE damages the Central Nervous System (CNS) in the developing fetus (Brown et al., 2012; Nash & Davies, 2017; Gorham, 2019; Popova, Lange, Burd, & Rehm, 2015). In fact, Chen, Maier, Parnell, and West (2003) found that cognitive and behavioral challenges are caused by the CNS damage rather than Intelligence Quotient (IQ) or other contributing factors alone. Despite this general understanding, the Canada FASD Research Network [CanFASD] (2019) reports that prevalence rates of FASD are 4% or 1.4 million Canadians. At least 1% of individuals in Saskatchewan have FASD with many more going undiagnosed (FASD Network, 2017). This may be because approximately 50% of adult pregnancies and 80% of adolescent pregnancies are unplanned (Nash & Davies, 2017). Nash and Davies (2017) found that only 9.4% of adults and 13.4% of teenagers drank during pregnancy, with each trimester seeing a reduction in drinking behaviors. This is compared to the 50% of adult women and 22% of teenage girls that drank before pregnancy (Nash & Davies, 2017). Thus, many individuals cease alcohol use once aware of their pregnancy but social inequalities, lack of education, and previous addictions may contribute to continued use in some cases (Migliorini et al., 2015), making PAE a societal reality (Gorham, 2019).

While we have known prevalence rates, it can be hard to get exact information about the amount, frequency of use, and developmental time of insult. Deciphering between abnormalities in the brain caused by PAE versus comorbid diagnoses – such as Attention Deficit Hyperactivity Disorder (40-90% of cases) and Specific Learning Disorders (17-35% of cases) (Glass et al., 2017) – and/or other substances used prenatally further complicates research (Lebel et al., 2011). Factors such as maternal metabolism, nutrition, and genetics also are hard to account for and testing theories is often unethical, thus resulting in animal studies that do not always translate to humans (Brown et al., 2012; Nash & Davies, 2017). Furthermore, while diagnosis of FASD involves a combination of facial abnormalities, tenth percentile growth deficits, and structural and functional CNS abnormalities (Brown et al., 2012), differences in brain structure and presentation occurs among individuals with PAE but who may or may not meet formal diagnostic criteria (Brown et al. 2012; Nash & Davies, 2017). Various anatomical and physiological abnormalities due to PAE have been observed, with the following showing up most frequently in the literature: microcephaly, reduced white and gray matter volumes, malformations in the frontal, parietal, and temporal lobes, corpus callosum abnormalities, and neural loss and communication issues (Lebel et al., 2011).

Anatomical Abnormalities: Microcephaly and Reduced White and Gray Matter Volumes

Reduced head size, called microcephaly, and reduced brain size and volume has been found in those prenatally exposed to alcohol (Chen et al., 2003; Fryer et al., 2012; Lebel et al., 2011; Nash & Davies, 2017; Stephen et al., 2012). The effects can be exasperated by being prenatally exposed to smoking in addition to alcohol (Nash & Davies, 2017). According to the Center for Disease Control and Prevention [CDC] (2018), microcephaly can lead to developmental delays, seizures, cognitive impairments, hearing and vision problems, and general issues with movement and balance – presentations often found in those with PAE.

Neuroanatomical abnormalities such as reduced white and gray matter volumes have been found in those with PAE, even after accounting for microcephaly and reduced brain volumes overall (Lebel et al., 2011). White matter volumes are particularly abnormal in the right hemisphere (Lebel et al., 2011). Eckstrand et al. (2012) found that the white matter loss lends itself to structural dysmorphology. Furthermore, Chen et al. (2003) found reduced white matter volumes in the parietal lobe and cerebral cortex. This can cause complications such as an abnormal metabolic rate of the thalamus and decreased communication to parts of the brain, such as the caudate nucleus (Chen et al., 2003).

Gray matter regions such as the caudate nucleus, thalamus, amygdala, hippocampus, basal ganglia, putamen, and pallidum appear to be particularly vulnerable to the effects of PAE (Eckstrand et al., 2012; Fryer et al., 2012; Lebel et al., 2011; Sharma & Hill, 2017; Zhou et al., 2015). Studies have shown that these areas are smaller (Lebel et al., 2011; Sharma & Hill, 2017), with certain areas seeing volume reductions of three to eleven percent (Zhou et al., 2015). This has vast implications on the individual, as these regions are responsible for important tasks: species-related behavior, memories, and emotions (amygdala and hippocampus); spatial perception (hippocampus); sensory integration (thalamus); and voluntary movement, attention control, explicit and reinforced learning, reward salience, and cognitive control mediation (basal ganglia) (Fryer et al., 2012; Kolb et al., 2019). For instance, Lebel et al. (2011) found that hippocampal volume and verbal abilities have an inverse relationship. Furthermore, Fryer et al. (2012) found that a reduction of volume in the caudate nuclei predicted lower neuropsychological performance, even after IQ was controlled for. They found that there was a decreased amount of glucose being metabolized in the caudate nuclei, impacting responses during behavior inhibition tasks. The caudate nuclei help with cognitive control and verbal learning and recall (Fryer et al., 2012) so it makes sense that abnormalities in this area would impact cognitive performance. It has been proposed that there is a dose-dependent relationship between alcohol consumption and caudate and gray matter volumes (Eckstrand et al., 2012; Fryer et al., 2012), but the specific dose has yet to be determined.

Anatomical Abnormalities: Frontal, Parietal, and Temporal Lobes

While the occipital lobe is relatively spared by the effects of alcohol, the same cannot be said for the frontal, parietal, and temporal lobes (Eckstrand et al., 2012; Lebel et al., 2011). These areas of the brain are responsible for executive functioning, voluntary movement, decision-making (frontal lobe), goal-oriented movement (parietal lobe), and senses, language, emotional processing, and facial recognition (temporal lobe), among many other functions (Kolb et al., 2016). The frontal lobe in those with PAE contains less white and gray matter volume. The parietal and temporal lobes also have less white and gray matter volumes due to narrowness of the lobes (Lebel et al., 2011). Additional anatomical abnormalities include thicker cortices, reduced gyrification, less temporal asymmetry, and displacement of the inferior parietal and temporal regions (Lebel et al., 2011). The structural brain damage in these regions has been linked to issues in cognition (Lebel et al., 2011) and planning, initiating, and controlling voluntary movements (Nguyen, Levy, Riley, Thomas, & Simmons, 2013).

Infante et al. (2015) found that those with PAE had reduced gyrification – cortical folding in the brain to create sulci and gyri to promote neuron connections and efficiency. Increased gyrification lends itself to higher IQs because the brain is making connections efficiently (Infante et al., 2015). Cortical folding typically occurs in the third trimester but no time in fetal development is safe from the harmful effects of alcohol (Infante et al., 2015). The reduced gyrification in the frontal and temporal cortices may present as cognitive and behavioral challenges, while reduced gyrification in the parietal cortex may result in issues with working memory (Infante et al., 2015). It is important to note that reduced gyrification has been found in those with ADHD and can be hard to differentiate from PAE due to comorbidity. However, Sharma and Hill (2017) found that there was a dose-dependent relationship between alcohol use and temporal lobe fusiform gyrus decreases. Thus, PAE likely also plays a role in reduced gyrification.

Differences in overall cortical thickness were found, particularly in the frontal and parietal lobes (Infante et al., 2015; Lebel et al., 2011; Zhou et al., 2015). In typically developing children, cortical surface area decreases as a result of brain maturity and efficiency; however, in those with PAE, cortical thickness was observed (Moore et al., 2017). This may account for differences in verbal learning (Lebel et al., 2011). Glass et al. (2017) used the Wechsler Individual Achievement Test – Second Edition (WIAT-II) to compare those with PAE to a normative control group. Those with PAE performed worse, struggling most with high-order math skills followed by numerical operations, spelling, and word reading. Over half of the cases (58%) in the PAE group were at least one standard deviation (SD) from the mean on one or more academic domains. Math difficulties were a result of parietal lobe abnormalities and spelling difficulties were a result of temporal lobe abnormalities (Glass et al., 2017). Glass et al. (2017) attributed this cognitive discrepancy to atypical brain development, cortical abnormalities, and the structural changes that were observed with neuroimaging.

Anatomical and Physiological Abnormalities: Corpus Callosum

 A particular area of concern is the corpus callosum – the largest white matter tract of 200 million fibres that is primarily responsible for hemispheric communication (Jacobson et al., 2017). It connects the cerebral hemispheres and provides a direct route for communication (Lebel et al., 2011; Jacobson et al., 2017; Kolb et al., 2019). The corpus callosum connects the neocortical areas and has a role in sensory, motor, and high-order communication (Jacobson et al., 2017). It develops during the second trimester during weeks 18 to 20 and increases in size during the third trimester and two years postpartum (Jacboson et al., 2017). If an individual is developing as expected, the corpus callosum will efficiently communicate from one cerebral hemisphere to another (Roebuck, Mattson, & Riley, 2002).

However, alcohol impacts genetic expression in this area of the brain (Nash & Davies, 2017). Both the shape and location of the corpus callosum are abnormal and complete or partial agenesis may occur (Eckstrand et al., 2012; Jacobson et al., 2017; Sowell et al., 2001; Sharma & Hill, 2017; Stephen et al., 2012), as well as colossal thinning (Lebel et al., 2011). The complete or partial agenesis may be due to toxic levels of alcohol being exposed during time of development or repeated insults impacting growth (Sowell et al., 2001). Lebel et al. (2011) found that the corpus callosum had smaller volume, area, and length and the shape variability increased with higher PAE. Jacobson et al. (2017) found that the corpus callosum was smaller, even after accounting for age, sex, and other prenatal toxins. Sowell et al. (2011) found that the corpus callosum was seven millimetres away on average from where it was supposed to be, impacting verbal learning and connectivity. This displacement, more so than the size discrepancy, impacts verbal learning (Lebel et al., 2011; Sowell et al., 2001), as interhemispheric communication is impaired.

In addition, the anterior cingulate cortex (ACC) – that surrounds the front of the corpus callosum – has reduced volumes and size, particularly on the right side (Infante et al., 2015; Migliorini et al., 2015; Roebuck et al., 2002). Migliorini et al. (2015) found that this resulted in slower inhibition completion time on the NEPSY-II subtests. ACC abnormalities can be attributed to executive functioning impairments, as this part of the brain has a role in conflict and error monitoring and information processing (Migliorini et al., 2015).

Various studies have shown the negative impacts of corpus callosum abnormalities due to PAE. Jacobson et al. (2017) attributed lower overall IQs and difficulties with verbal comprehension and processing speed on the Wechsler Intelligence Scale for Children – Fourth Edition (WISC-IV) to abnormalities in the corpus callosum. The midline structures, such as the hippocampus, that communicate with the corpus callosum were impacted (Jacobson et al., 2017); they surmised that the lack of transfer due to midline structural impairments likely lead to the poorer performance by the PAE group (Jacobson et al., 2017). Furthermore, Donald et al. (2016) found that in the corpus callosum there was a white matter connectivity issue. Connectivity between the caudate and executive functioning networks was limited, impairing perceptual reasoning and thalamus connectivity. Roebuck et al. (2002) found that those with PAE made more errors when information had to cross the corpus callosum but fewer errors if information was uncrossed. Thus, tasks with increased complexity resulted in more frequent errors. The interhemispheric transfer was viewed through magnetic resonance imagining (MRI) and complications were related to abnormal corpus callosum size (Roebuck et al., 2002). They found that the displacement of the corpus callosum and ineffective processing between the two hemispheres led to cognitive and psychosocial impairments. Brown et al. (2012) attributed executive functioning deficits to corpus callosum malformation due to neural communication complications. In addition, colossal thinning has been connected to poor motor skills (Lebel et al., 2011; Roebuck et al., 2002). Thus, the presentations we see in those impacted by PAE may occur because of brain connectivity and communication issues.

Physiological Abnormalities: Neural Loss and Communication Issues

Functional abnormalities, such as cellular alternations and neural loss, can occur due to PAE (Chen et al., 2003; Eckstrand et al., 2012). Nash and Davies (2017) explain that the toxic byproducts left behind by alcohol – especially in individuals without the alcohol dehydrogenase enzyme that metabolizes alcohol – can lead to abnormal cell growth and division leading to neurological system abnormalities. In other words, alcohol disrupts cell growth and migration (Eckstrand et al., 2012). Issues in cell migration – often due to agenesis, poor myelination, poor axonal integrity, or thinning – complicate transmission to dendrites in the cortex, hippocampus, and other important brain structures (Jacobson et al., 2017; Migliorini et al., 2015). Thus, PAE impacts cell migration from the production to the end site, impacting cell communication (Chen et al., 2003). Chen et al. (2003) found that there are less dendrites for communication in general. They further explain that neural loss and cell communication difficulties can present as cognitive and behavioral concerns.

Conclusion

PAE has detrimental effects on the developing fetus that last a lifetime. While many parts of the brain are impacted, microcephaly, reduced white and gray matter volumes, malformations in the frontal, parietal, and temporal lobes, abnormalities in the corpus callosum, and neural loss and communication issues are of most concern (Lebel et al., 2011). These anatomical and physiological impairments have far-reaching effects in areas of verbal reasoning, motor functioning, global IQ, and social abilities. Lebel et al. (2011) state that reduced size of the hippocampus and corpus callosum correlates with the number of days spent drinking in a week while pregnant. Furthermore, the amount of alcoholic beverages consumed relates to frontal lobe, caudate nuclei, and hippocampus volume decreases (Lebel et al., 2011). However, additional research is required to further understand the brain abnormalities and their effects. Assessment, interventions, and supports for those with PAE should improve as we better understand the specific CNS impairments and how the environment exasperates these anatomical and physiological abnormalities.

Works Referenced

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CanFASD: Canada FASD Research Network (2019). Diagnosis. Retrieved from: https://canfasd.ca/topics/diagnosis/

Center for Disease Control and Prevention (CDC) (2018). Facts about microcephaly. Retrieved from: https://www.cdc.gov/ncbddd/birthdefects/microcephaly.html

Chen, W. A., Maier, S. E., Parnell, S. E., & West, J. R. (2003). Alcohol and the developing brain: Neuroanatomical studies. Alcohol Research & Health, 27(2), 174-80.

Donald, K., Ipser, J., Howells, F., Roos, A., Fouche, J., Riley, E.,… Stein, D. (2016). Interhemispheric functional brain connectivity in neonates with prenatal alcohol exposure: Preliminary findings. Alcoholism: Clinical and Experimental Research, 40(1), 113-121.

Eckstrand, K. L., Ding, Z., Dodge, N. C., Cowan, R. L., Jacobson, J. L., Jacobson, S. W., & Avison, M. J. (2012). Persistent dose‐dependent changes in brain structure in young adults with low‐to‐moderate alcohol exposure in utero. Alcoholism: Clinical and Experimental Research, 36(11), 1892-1902

FASD Network of Saskatchewan Inc. (2017). Fetal alcohol spectrum disorder: A guide to awareness and understanding.

Fryer, S., Mattson, S., Jernigan, T., Archibald, S., Jones, K., & Riley, E. (2012). Caudate volume predicts neurocognitive performance in youth with heavy prenatal alcohol exposure. Alcoholism: Clinical and Experimental Research, 36(11), 1932-1941.

Glass, L., Moore, E., Akshoomoff, N., Jones, K., Riley, E., & Mattson, S. (2017). Academic difficulties in children with prenatal alcohol exposure: Presence, profile, and neural correlates. Alcoholism: Clinical and Experimental Research, 41(5), 1024-1034.

Gorham, K. (2019). Best practices: Fetal Alcohol Spectrum Disorder (FASD). (Unpublished essay). University of Regina, Saskatchewan. 

Infante, M., Moore, E., Bischoff-Grethe, A., Migliorini, R., Mattson, S., & Riley, E. (2015). Atypical cortical gyrification in adolescents with histories of heavy prenatal alcohol exposure. Brain Research, 1624, 446-454.

Jacobson, S. W., Jacobson, J. L., Molteno, C. D., Warton, C. M. R., Wintermark, P., Hoyme H. E.,… Meintjes, E. M. (2017). Heavy prenatal alcohol exposure is related to smaller corpus callosum in newborn MRI scans. Alcoholism: Clinical and Experimental Research, 41(5), 965-975.

Kolb, B., Whishaw, I., & Teskey, G. (2016). An introduction to brain and behavior(6th ed.). New York: Worth Publishers.

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Nash, A., & Davies, L. (2017). Fetal alcohol spectrum disorders: What pediatric providers need to know. Journal of Pediatric Health Care, 31(5), 594-60.

Nguyen, T., Levy, S., Riley, E., Thomas, J., & Simmons, R. (2013). Children with heavy prenatal alcohol exposure experience reduced control of isotonic force. Alcoholism: Clinical and Experimental Research, 37(2), 315-324.

Osterman, R. (2011). Decreasing women’s alcohol use during pregnancy. Alcoholism Treatment Quarterly, 29(4), 436-452.

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Stephen, J. M., Kodituwakku, P. W., Kodituwakku, E. L., Romero, L., Peters, A. M., Sharadamma, N. M., . . . Coffman, B. A. (2012). Delays in auditory processing identified in preschool children with FASD. Alcoholism, 36(10), 1720-7.

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Chicka Chicka Boom Boom

Chicka Chicka Boom Boom has to go down in history as one of the best primary books! My students enjoyed listening to the song, reading the story, adding letters to our stuffed coconut tree, making their own themed name trees, and seeing their support teacher dressed up as the famous tree for Halloween!

See resource at: https://www.pinterest.ca/pin/535506211938406485/

Reading and Writing Strategies

Improving writing instruction is one of my professional growth goals this year. As a school, we are working to have 65% of our students writing at or above grade level and 90% of our students reading at or above grade level by June 2020. This summer I took some time to read 6+1 Traits of Writing: The Complete Guide for the Primary Grades by Ruth Culham, Using Picture Books to Teach Writing with the Traits by Ruth Culham and Raymond Coutu, Reading Power by Adrienne Gear, The Reading Strategies Book and The Writing Strategies Book by Jennifer Serravallo. I would highly recommend all of these books for primary teachers and beyond. I was able to select strategies for literacy instruction that aligned with our Saskatchewan Reads document and Gr. 1/2 Curriculum and our Ways to Take Action decoding strategies that our primary team uses. Please view the attached document for some of the strategies that my primary literacy cluster (co-teaching group of 2 classroom teachers, 2 SSTs, and our principal) will be utilizing:

Writing strategy for independent writing stamina

Reading is succeeding! Happy teaching!

Ethical Issues Relevant to Assessment

Ethical Issues Relevant to Assessment by Kourtney J. Gorham

University of Regina

EPSY 829: Ethics and Professional Practice 

Introduction

The skillset and knowledgebase of psychologists is highly respected within our society, with psychological assessment often earning the highest regard (Koocher & Rey-Casserly, 2003; Turchik, Karpenko, Hammers, & McNamara, 2007). The testing business was estimated to be a 400 to 700 million dollar industry in the early 2000s and it continues to grow (Clarke, Madaus, Horn, & Ramos, 2001; Public Broadcasting Services (PBS), 2002). Psychological assessments are tools that help psychologists derive objective information about an individual’s abilities, weaknesses, interests, learning capacities, and potential diagnoses. Psychological assessments differ from informal tests and online measures because they include an in-depth assessment of the person through the referral question(s) asked and require specific procedures for how the test is managed and scored by a qualified professional (Naglieri et al., 2004). However, ethical issues can occur when the assessment is not used as intended. In these instances, the measure may overshadow the individual being assessed and/or fail to answer the referral questions (Adams & Luscher, 2003; Turchik et al., 2007). Psychologists need to use clinical judgement when deciding when and if to assess and determine if psychological assessment will lead to intervention and support rather than simply a number or score on a report.

Koocher and Rey-Casserly (2003) noted that psychological assessments can have both a negative and positive impact on people. Negative outcomes may include diagnostic labels, unanswered questions, legal trials, job loss, university admission challenges, and wait-times for assessment and services (Evans, 2011; Koocher & Rey-Casserly, 2003; Michaels, 2006). Furthermore, assessment can impact how the client views themselves and is viewed by others; stigmas and negative judgements may be formed (Michaels, 2006). Take, for instance, the misinterpretation of diagnostic labels, test scores, Intelligence Quotients (IQ), and personal descriptors that can find their way into conversations and formal documents, such as an Inclusive Intervention Plan in the school setting (Michaels, 2006). Unfortunately, both laypersons and professionals may misinterpret psychological assessment and this can negatively impact a person’s life course. It becomes easy to reduce someone to a score on a psychological report and forget the human and personal factors not accounted for in formal testing.

However, while there are negative aspects to psychological assessment, there are also many benefits. If a person is properly assessed this will increase their self-awareness about what is going on and thus, their ability to advocate for the services and supports they need. While a diagnosis can lead to a label, it also ensures that evidence-based resources, supports, and interventions are being used. Assessment also acts as a tool to determine and validate who gets certain supports in our school systems and other social programs (Dombrowski & Gischlar, 2014). It acts as a concrete way to determine funding and can connect individuals to much-needed outside agency supports.

Because psychological assessments have both negative and positive impacts on individuals, we can view them as being both ethical and unethical. Koocher & Rey-Casserly (2003) note the importance of considering all ethical aspects before, during, and after assessment. While this is no small feat, by using the ethical standards set forth by the Canadian Psychological Association’s Canadian Code of Ethics for Psychologists (2017) and the Saskatchewan College of Psychologists’ Professional Practice Guidelines (2010), psychologists in Saskatchewan can ensure they avoid ethical issues related to competency, informed consent, and confidentiality when assessing clients.

Competency

Competency is the area of expertise that a psychologist has developed through their education and supervision, as well as their own professional development pursuits (Adams & Luscher, 2003; Koocher & Rey-Casserly, 2003). Standards II.6 and II.9 of the Canadian Code of Ethics for Psychologists (2017) highlight that a psychologist must work within their area of competency (CPA, 2017). Thus, when it comes to assessment, a psychologist must first assess their own capabilities before working with the client. Self-assessments of competency also must include up-to-date knowledge of testing psychometrics. A psychologist must be trained in assessment selection, procedures, scoring, and interpretation as per the standards set forth by the Canadian Psychological Association (2017) and the Saskatchewan College of Psychologists (2010) (CPA II.9; SK 14.2). In general, a knowledgebase in validity, reliability, norms, standardization, standard error of measurement, false positives and negatives, sensitivity, specificity, test specifications, and convergent validity of multiple assessments (Adams and Luscher, 2003; Evans, 2011) is required in the broad sense and specifically in regards to each specific assessment measure to be used. Psychologists must critically select tests by weighing the pros and cons and researching them beyond the publisher’s self-reports (Evans, 2011; Koocher & Rey-Casserly, 2003).

Psychologists need to assess their own bias when selecting tests, especially when working for agencies that may prefer one assessment over another due to financial or accessibility reasons (Koocher & Rey-Casserly, 2003). Turchik et al. (2007) note that tests are frequently updated and this may cause financial barriers. There is a cascade of costs if multiple kits, testing forms, and computer interpretation programs are required or the agency serves a wide variety of needs. Furthermore, one measure may not be sufficient (Adams & Luscher, 2003). The Professional Practice Guidelines (2010) highlight the need to use the most recent edition of assessments (SK 14.5).

Both Koocher and Rey-Casserly (2003) and Simner (1994) argue that if a psychologist is not trained in testing psychometrics than they cannot critically judge the test features and thus its applicability to the situation, referral question(s), and individual. The Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010) note that test selection is done on a case-by-case basis, using methods that are valid to the population and questions sought (CPA II.13; CPA II.18; SK 14.3; SK 14.4). This requires careful consideration that the client’s language, race, educational level, culture, and age match the norm group, as well as the adequacy of the instrument to meet the identified need (Koocher & Rey-Casserly, 2003). It is important to note that, an assessment can be psychometrically sound but fail to meet the client’s needs and/or answer the referral question(s) (Adams & Luscher, 2003). In many cases, multicultural groups and those with disabilities have been left out of the norm groups. While adaptations can be made and reported on to accommodate this as per standard 14.3 (SKCP, 2010), these adaptations need to be reported and cannot impact the overall validity of the test (Koocher & Rey-Casserly, 2003). For instance, an interpreter or nonverbal measure may be used if a person speaks a different language but it is important to ensure comprehension of the questions asked, fidelity to the questions asked, and that the measure itself is being tested versus language (Evans, 2011; Koocher & Rey-Casserly, 2003). The Canadian Code of Ethics for Psychologists (2017) includes standards on respecting others regardless of these differences (CPA 1.1) and evaluating our own biases (CPA III.15). Ensuring our own competency and the applicability of an assessment measure is one way to ensure that these standards are met.

Informed Consent

Informed consent is a shared decision-making process that starts from the outset and continues throughout the professional relationship (Barnett, Wise, Johnson-Greene, & Bucky, 2007). From a legal standpoint, the client must give consent voluntarily and they must comprehend and thus, have the capacity to do so (Barnett et al., 2007; Evans, 2011). This is represented in the Canadian Code of Ethics for Psychologists (2017): consent must be voluntarily given (CPA I.27), all the information that a reasonable person would need to make an informed decision must be shared and updated throughout the process (CPA I.23; CPA I.25), and the information must be presented at an attainable level for all involved (CPA I.24). From the outset, Simner (1994) recommends that the client(s) receive honest information about what the assessment process can reasonably uncover. Adams and Luscher (2003) stress the need for written and oral language that matches the client’s level of understanding. The informed consent piece is vital to ethical assessments from the outset because it allows reasonable expectations to be set, clarification of the referral questions and goals, and can be telling of the client’s desires and hopes of assessment.

Assessment of minors poses an additional challenge because minors are often referred by third-parties, such as school teams and caregivers (Koocher & Rey-Casserly, 2003). In these instances, it is the caregivers who provide consent (Adams & Luscher, 2003; Koocher & Rey-Casserly, 2003; Tan, Giovanni, Passerini, & Stewart, 2007). The Canadian Code of Ethics for Psychologists (2017) states that consent is granted from caregivers of children (CPA I.34), but active participation occurs from all involved (CPA I.19) and clarification of multiple relationships, such as third-parties (CPA I.26), is carefully established so that the psychologist knows who to serve. When it comes to assessing children, psychologists need to determine who the client is – for instance, the caregiver who pays the fees, the child who is being assessed, or the school who requires the assessment results for placement decisions – and if the goals of all parties involved align (Koocher & Rey-Casserly, 2003).  Further challenges include determining if the child understands what they are consenting to (Adams & Luscher, 2003) and ensuring that they have not being coerced intentionally or unintentionally by the adult influences in their life. For psychological assessment to be ethically conducted on children, it is essential that the psychologist does not allow third-party desires to result in assessment bias (Koocher & Rey-Casserly, 2003). Adherence to the informed consent codes can help psychologists ethically conduct assessments of minors.

Confidentiality          

Confidentiality is the client’s right to privacy and autonomy. Michaels (2006) noted that assessment may uncover information that did not relate to the original purpose. There may be pressure to disclose additional information gathered to the school team (Bhola & Raguram, 2016) and pressure to change results when they are not favorable or as expected (Koocher & Rey-Casserly, 2003). In these instances, the psychologist must use clinical judgement to determine what to share and include in the report. The Professional Practice Guidelines (2010) indicate that the psychologist must work directly with the client and they are responsible for accurate interpretations based on up-to-date information, even when computer interpretation programs are used (SK 14.6; SK 14.7; SK 14.9). Koocher & Rey-Casserly (2003) also note the importance of ensuring tests were appropriately scored – especially when using computer-automated tools – and noting any limitations. Any modifications, such as errors, changes to the release of information, and omission of data that is unnecessary to share, should be noted and corrected (Koocher & Rey-Casserly, 2003). In any case, reporting should be clear and objective with a strengths-based style to ensure minimal harm to the client (Michaels, 2006). The results must be accurately reported, even when unfavorable. Tranel (1994) and Knauss (2001) recommend that when reporting results, assume anyone can read it, including the legal system, to avoid unprofessionalism and opinion-based reporting. The Canadian Code of Ethics for Psychologists (2017) is clear that the reports must be objective (CPA III.10), related only to the questions sought (CPA I.37), and regardless of the communication mode, information must be shared in a way that respects the client’s right to privacy (CPA I.41).

It is important to consider testing factors when interpreting and reporting on assessment results. Threats to internal validity must be considered, such as testing effect, maturation effect, or statistical regression effect (Neuman, 2011). External and internal factors, such as being tired, hungry, or bored, may impact a child’s performance. Furthermore, the relationship with the psychologist may not be adequate in the child’s opinion and they may not feel comfortable or able to do their best. They may perform poorly due to lack of exposure versus cognitive deficits. These factors can affect overall results and are harder to track with high-risk populations, such as children (Flanagan, Sotelo-Dynega, & Caltabiano, 2010; Russell, Norwich, & Gwernan-Jones, 2012). Tranel (1994) notes that, along with the test findings, applicable diagnoses, and relevant recommendations, a report should include background history and the setting and environmental factors noted during testing. Koocher & Rey-Casserly (2003) recommend noting any testing behaviors in the final report that may better explain the results. In fact, psychological assessment differs from other measures by how meaning is derived through accurate administration and interpretation of all relevant factors (Jacob-Timm, 1999; Knauss, 2001), including testing conditions.

Assessment reporting has both confidentiality and informed consent considerations. As per the Canadian Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010), it is the psychologist’s job to ensure understanding, highlight opinions in an unbiased and professional manner, and explain the assessment in a variety of culturally-appropriate ways for all parties involved (CPA II.20; CPA II.32; SK 14.1; SK 14.8). Unfortunately, often when assessing children the information is more likely to be shared with the caregivers and school team without including the child. In addition, this information can be hard to understand. Tranel (1994) notes that scores, taken out of context, have no meaning. Furthermore, reports and technical terms are not always accessible to caregivers and educators even after explanations are given. This creates an ethical challenge because the caregivers and educators are the ones who will likely be implementing the strategies with the child and need to understand the results, including what the scores and percentile ranks mean (Flanagan et al., 2010; Lefaivre, Chambers, & Fernandez, 2007). Furthermore, it is of the highest ethical standard to ensure that recommendations are being followed. An ethical challenge occurs when caregivers do not follow-through with recommendations in reports, such as not attending a doctor appointment or attending family counselling, after the psychologist has made the referral.

Additional Considerations

Another area of consideration includes keeping the tests themselves confidential. If a client has been pre-exposed to testing materials, including from previous versions of the test, this causes an internal threat to validity through testing effect and diffusion of treatment (Koocher & Rey-Casserly, 2003; LoBello & Zachar, 2007; Neuman, 2011). LoBello & Zachar (2007) found 82 psychological tests for sale on Ebay during a three month period; unfortunately, 48% had no restrictions on buyer credentials and many of the sales showed pictures of test materials that could be compromising. Similarly, Tranel (1994) found that test manuals that should only be available to licensed psychologists were accessible in bookstores and online sales. This can also become an ethical issue if tests are not disposed of appropriately (LoBello & Zachar, 2007) or if reports or tests are photocopied and/or left behind after a meeting. Adams and Luscher (2003) note that in order to protect assessment validity, clients should never take test materials home. Furthermore, assessments should be stored securely as per standard I.41 (CPA, 2017). 

Psychologists may be pressured to release reports to third parties, such as schools, caregivers, insurance providers, and the legal system. This can be particularly challenging in regards to the legal system because the laws and ethics often clash and all information, scores, and notes can be subpoenaed (Koocher & Rey-Casserly, 2003; Tranel, 2003). When psychologists have client’s assessments subpoenaed these materials need to be sealed after the trial and may require publishers to fight copyright on their own behalf (Koocher & Rey-Casserly, 2003). Assessments should only be interpreted by a licensed psychologist to ensure minimum harm to the client due to copyright issues and proper interpretation of raw scores (Koocher & Rey-Casserly, 2003; LoBello & Zachar, 2007; Michaels, 2006; Tranel, 1994). Both the Canadian Code of Ethics for Psychologists (2017) and the Professional Practice Guidelines (2010) are clear that we need to protect the physical tests and methods used (SK 14.10) and testing techniques and interpretations from being misused (CPA IV.11).

Conclusion

The Canadian Psychological Association’s principles – Respect and Dignity of the Person, Responsible Caring, Integrity and Relationships, and Responsibility to Society – need to be at the forefront of our assessment practices. Psychological assessment can be challenging to do ethically; Kirby et al. (2009) note that only 16% of individuals receive an accurate diagnosis and out of those with an accurate diagnosis, only 16% of adults and 10% of children receive adequate supports (as cited in Mash & Wolfe, 2019). However, there are both positive and negative outcomes of psychological assessment and thus, it is not a practice we can simply discontinue. Instead, we need to use the codes and standards to guide our practice before, during, and after assessment so that we can ensure minimal harm and maximum benefit to clients. Alternatives to assessment, such as barrier-free approaches are an option but they pose their own challenges. For instance, many of our Autism Resource Centers in Saskatchewan only require a brief initial observation or a brief screener to receive supports rather than a formal assessment and diagnosis. While this speeds up the process for some children who require the supports, others are overlooked due to the lack of scope and sequence in brief screeners and the crossover of many of the diagnostic categories. Furthermore, some children are supported when they may have other conditions, such as Attention Deficit Hyperactivity Disorder (ADHD) and would be better served by other empirically supported means. While the child may not have received the diagnostic label, caregivers and educators tend to adopt these once the child is accessing services, despite formal assessment to confirm these claims. In the end, although psychological assessment can be an ethical minefield, it continues to prove valuable. If we continue to find ways to conduct assessment in adherence with the ethical codes, the answers derived will ensure maximum benefit for the clients and society that we serve.

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