Brain impairment
in FASD

Alcohol use during pregnancy can damage the development of any part of the brain.

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Brain impairment can be assessed against nine neurodevelopmental domains.

The diagnosis of FASD requires severe and pervasive impairment in at least three of these domains. Additionally, impairment should manifest in functional impact requiring support.

People with FASD have their own individual strengths and interests, but all experience a degree of difficulty in everyday activities and will likely need additional support to thrive.

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Nine neurodevelopmental domains relevant to the diagnosis of FASD

Frontal lobe

Frontal Lobe

Parietal Lobe

Cerebellum

Motor skills

Motor skills include general motor abilities, areas of fine motor, gross motor, graphomotor (handwriting) skills, and/or visual motor integration.

  • Fine motor skill difficulties: fine motor skills require using the small muscles in the fingers, hands and forearms – picking up items, holding a pen, writing and drawing, using scissors, and doing up buttons and laces.
  • Problems with gross motor skills: gross motor skills require whole body movement – everyday activities such as standing, walking, running, climbing, riding a bike or scooter. A person with FASD may have trouble learning to ride a bike, trouble coordinating arms and legs when running, falling over more commonly than other kids.
  • Floppy or stiff limbs.
  • Poor eye hand coordination, lacking the ability to coordinate vision with movement.
  • Delayed skills e.g. picking up and stacking blocks in a tower, making Duplo or Lego models.

  • Help the person participate in activities they like such as football, bowling, swimming, dancing, playing the drums.
  • Plan fun physical activities and play with the child – activities do not need to be formal sessions in a therapy room.
  • Lead by example and show the child how to do the activity by breaking the activity into parts e.g. catching a ball- how to hold hands, where to look, what to do when ball hits the hand.
  • Remember the language and memory strategies when teaching them new skills.
  • Encourage a child to use their hands – e.g. daily use of pencils, puppets, play dough.
  • Help with tasks such as doing up buttons, tying shoelaces – it may take many children with FASD longer to learn and they will need to repeat the activity more frequently and for a longer period of time. Practice on toys that have clothes and shoes, own items of clothing not being worn.
  • Be aware of the persons attention span e.g. they may only be able to do the activity for a shorter period of time compared to other children the same age.
  • Provide breaks between activities.

Frontal lobe

Frontal Lobe

Occipital Lobe

Temporal Lobe

Intellectual abilities

Health professionals should apply generally accepted models of intelligence, which is often defined to include the capacity for abstraction, to solve problems and acquire new skills.

It is how we learn, problem solve, pay attention, verbal and non-verbal reasoning skills, processing speed, and working memory.

  • Difficulty understanding concepts.
  • Difficulty learning new skills or facts.
  • Difficulty remembering what was previously learned.

  • Break requests or instructions into small pieces of information.
  • Have structure – what is first, what you need to do next.
  • Use visual aids e.g. photos, cartoons.
  • When assisting a person with FASD you need to be organised to help the activity/lesson go as smoothly as possible.
  • Check the tips in the communication, memory, and attention sections.

Frontal lobe

Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Cerebellum

Basal ganglia (includes Caudate Nucleus)

Corpus Callosum

Broca area

Wernicke area

Hippocampus

Amygdala

Cranial nerves

Communication

Communication includes language skills, conveying ideas, thoughts, and feelings to others.

Language skills refer to the words, syntax, morphology, and pragmatics we use to understanding and communicate oral, sign, and written forms.

  • May not understand instructions or their intent e.g. keep away from the hot stove.
  • Can’t find the right word, uses the wrong word, can’t communicate intent, can’t structure a sentence.
  • Engages in an apparently meaningful conversation but is unaware of the meaning of what is being said.

  • Talk in simple terms – keep it short and sweet.
  • Ask open-ended questions (not yes or no questions).
  • If the child can read, write things down, if they can’t get them to draw pictures.
  • Take your time when speaking.
  • Give the person lots of time to think and respond.
  • Use visual aids as much as possible.
  • Use post-it notes, draw pictures or cartoons to tell a story or get them to tell a story.
  • Summarise the conversation often, and get them to relay for you to check they understand what they need to do.

Frontal lobe

Frontal Lobe

Temporal Lobe

Parietal Lobe

Occipital Lobe

Literacy and/or numeracy skills

Literacy refers to reading, writing, and spelling skills and numeracy refers to mathematics skills.

  • Poor performance at school and in external tests compared to other children.
  • Not achieving at the same level as other children of the same age.
  • May have specific learning problems e.g. with maths (doesn’t understand the abstract concepts), doesn’t understand the concept and value of money.
  • Doesn’t understand time and hence may not get to school or work on time.
  • Can do the activity e.g. learning new word in spelling or reading today, but not tomorrow.

  • Use explicit teaching methods – actively involving them in the learning process and have realistic goals.
  • Teach one step/or part of an activity or lesson at a time.
  • Use a digital watch/clock rather than watch/clock with face and hands.
  • For a teenager or adult with a mobile phone, program alarms and information on the next activity or appointment, a reminder that they need to go to the bus stop or buy their food, pay their electricity account.
  • Will require a lot of repetition to master tasks – lots of patience from the person helping e.g. parent, teacher. Praise and acknowledge when they achieve the goal.

Frontal lobe

Frontal Lobe

Occipital Lobe

Temporal Lobe

Memory

Memory includes the ability to encode, store and retrieve information.

  • May have trouble remembering things that happened yesterday (short term) or in the past (long term) – including school work or daily routines.
  • Failure to remember and learn from experience.
  • Often don’t remember things in the correct sequence e.g. recounting the day at school or giving evidence in court.
  • Forgetfulness.

  • Be consistent with words or terms used
  • Break information into smaller chunks
  • Present information in a variety of contexts e.g. crossing the road at a crosswalk – go to different places so they don’t think it only applies to the crosswalk outside school
  • Find strategies that work for the individual and helps them memorise information or facts
  • Be organised (e.g. first, next, last)
  • Be direct
  • Provide visual aids
  • Include nature and real-life experiences
  • Use music and rhymes (clapping, tapping, singing)
  • Play matching games
  • Provide opportunities for learning or play where there are fewer distractions, quiet environment (make cubby out of big box)
  • Provide lots of opportunities for practice and repetition (make it fun and OK to make mistakes)
  • Make eye contact when working one-on-one
  • Write things down and draw pictures
  • Present information in a clear, simple and short format (e.g. lists or timetable)
  • Ask them to repeat information back or summarise the main parts of the conversation
  • Use other cues to help their memory – clothes lined up at child’s door so they are aware of school days and weekends
  • For a teenager or adult with a mobile phone, program alarms and information on the next activity or appointment, a reminder that they need to go to the bus stop or buy their food, pay their electricity account

Frontal lobe

Frontal Lobe

Temporal Lobe

Parietal Lobe

Attention

Attention has several components:

  • selective attention – focussing on a particular stimulus
  • divided attention – focussing on two or more stimuli at a time
  • alternating attention – switching focus from one stimuli to another
  • sustained attention – attending for a long period of time and resistance to distractions.

Attention deficits usually manifest as problems with concentration, task focus and work organisation.

In many definitions and theories of brain function, attention overlaps with some of the executive functions. In order to distinguish these domains for diagnostic purposes in FASD, attention has been defined separately.

  • Problems with concentration, focusing on a task and completion of tasks at school, home or work.
  • Attention problems may occur with or without hyperactivity.

  • May need to have shorter times for activities and breaks between – if they have been sitting and are starting to fidget, allow them to take time to move around (applies to school and home).
  • Minimise noise and other distractions – have a quiet corner where they can go and put on headphones to block out noise.
  • Use daily planners – visual cues for younger children and written lists, notes or phone messages for young people so they can see or read what they have to do next.

Frontal lobe

Frontal Lobe

Executive function

Executive function refers to a set of higher-level skills involved in organising and controlling one’s own thoughts and behaviours in order to fulfil a goal with maximum efficiency.

For the purpose of FASD diagnosis it includes:

  • impulse control (characterised by actions without forethought, which often have potential for harm to self or others)
  • inhibition response
  • hyperactivity (characterised by inappropriate and excessive levels of motor activity or speech)
  • working memory
  • planning and problem solving
  • shifting and cognitive flexibility.

While in many definitions and theories of brain function attention overlaps with some of the executive functions, they have been defined separately for diagnostic purposes in FASD.

  • Trouble planning a complex task.
  • Trouble knowing where to begin a task – whether school activity or playing a game.
  • Trouble moving from one activity to another in the home or school environments e.g. moving from music lesson to maths
    lesson, stop playing a game and get ready for dinner.
  • Acting without thinking e.g. disruptive and/or aggressive behaviour in the classroom, hyperactivity.
  • May call out or act out in the classroom when they are not sure what to do or can’t do something.
  • Harm to others and self-harm.

  • Guide the person to think through problem solving, give them lots of practical examples and demonstrate how to do this yourself (e.g. thinking out loud).
  • Model good behaviour and decision making yourself.
  • Remind them it is okay to make mistakes, but is important to try again.
  • Talk about goals and how to achieve them.

Temporal Lobe

Frontal lobe

Frontal Lobe

Emotional and/or Behavioural Regulation

Emotional and/or behavioural regulation could include significant difficulties with any of the following:

  • Mood: internalising symptoms such as depression or anxiety, negative affect, suicidal ideation)
  • Emotional regulation: irritability, low frustration tolerance, mood lability, suicide threats, where this is not the direct impact of another aetiology).
  • Behavioural regulation: externalising behaviours could include rule-breaking behaviour (e.g., confabulation, taking things that belong to others), oppositional/non-compliant, behavioural outbursts, and reactive aggression.

  • Very emotional with swings from sad to happy – often not sure why they are sad.
  • May have anxiety or depression, panic attacks.
  • Separation anxiety or disorders of attachment e.g. when children are removed from their family and children with multiple out of home care placements.

  • Where possible avoid situations that may be stressful or cause anxiety.
  • Plan changes well ahead and talk about what is going to happen e.g. going on holidays, moving household furniture (particularly in their bedroom or playroom).

Frontal lobe

Frontal Lobe

Parietal Lobe

Temporal Lobe

Adaptive behaviour

Life skills which enable an individual to live independently in a safe and socially responsible manner; and how well they cope with everyday tasks.

These include:

  • conceptual skills – language, reading, maths, reasoning, knowledge and memory
  • social skills – empathy, social judgement, interpersonal skills, the ability to make and retain friendships
  • practical skills – self management in areas such as personal care and daily living skills, job responsibilities, money management, recreation, and organising school and work tasks.
  • Difficulties in self-care, independent and day to day living without assistance, difficulties managing money e.g. don’t pay bills.
  • Socially and financially gullible.
  • Difficulty with relationships e.g. children with developmental delay may play/socialise with younger children, indiscriminate expression of affection, overly friendly and at risk of predatory behaviours.
  • Difficulty recognising and responding to social cues.
  • Difficulty making and keeping friends.
  • Subject to teasing and bullying.
  • May demonstrate features of Autism Spectrum Disorder.
  • Use explicit instruction – directly engaging the person in learning social skills. Requires modelling, coaching, rehearsing or practicing (families, teachers, coaches).
  • Use role play activities to help them understand what they need to do (e.g. how to cross the road, how to find an item at the shop and pay for it).
  • Put systems in place to help with knowing what to do or where they can go, such as visual charts in house which have pictures showing what needs to be done before or after school.
  • Put automatic reminder mechanisms in place to assist the person on where or what they should be doing at a specific time (e.g programming into mobile phone).

Assessment and diagnosis of FASD

Assessment and diagnosis of FASD is based on the Australian Guidelines for Assessment and Diagnosis of Fetal Alcohol Spectrum Disorder
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