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Mental Health 2016-17

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Margaret L. Stivers, Ph.D.
Clinical Psychologist

Margaret is a clinical and social psychologist trained at the University of Kansas and the University of Miami. She has taught psychology at four major universities and directed mental health, residential, and nonpublic school programs for children and adolescents. Her experience includes 30 years of consultation and collaboration with educational programs throughout the country, including schools in urban and rural areas and on Indian reservation.

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  • new!Implications of FASD for learning and behavior in 2nd grade student

Question:

I am a second grade teacher and we have a boy who has been diagnosed with Fetal Alcohol Syndrome. He continues to be non-compliant in class and display outbursts of emotion (which are usually verbal but can sometimes escalate to physical acts). We have gathered behavioral data and implemented many strategies in order to reduce the frequency and severity of his outbursts. Although these efforts have been somewhat successful, our focus has been on behavior management and keeping him and the other students safe.

Could you provide us with information about FAS? Also, are there any medications or strategies you can recommend that might help us to help him access the curriculum and experience more academic success?


Answer:

Thank you for your questions. The DCN behavioral pediatrician and clinical psychologist have prepared a joint response to your question. We will begin by considering the ways in which the consumption of alcohol by a pregnant woman might contribute to the problems you identify in your student.

Alcohol appears to be the most toxic of the substances used by expectant mothers (even more so than heroin, cocaine and methamphetamine). Damage is believed to result from any of a number of possible mechanisms, which include: direct teratogenicity during embryonic development; alterations in the ability of the fetus to synthesize proteins, prostaglandins, and hormones; reduction in nutrient and oxygen delivery to developing brain cells; and alteration in neurotransmitter levels in developing brain neurons. Each of these mechanisms can cause changes in brain structure and function.

How much damage occurs and what functions are affected are determined by a complex (and incompletely understood) interaction between multiple factors: the amount, pattern, timing, and duration of the exposure; genetic factors; mother’s general nutritional and health status, usage of other substances known to be toxic to developing brain tissue, and exposure to high levels of stress and or trauma during her pregnancy. The potential variability implicit in this complex interplay helps account for the broad spectrum of effects seen in children exposed to alcohol prenatally.

Diagnostic labels used to describe the effects of prenatal alcohol exposure have evolved over the last 3 decades. Terms used currently for diagnosis include Fetal Alcohol Syndrome (FAS), Partial Fetal Alcohol Syndrome (pFAS), and Neurobehavioral Disorder-Associated with Prenatal Alcohol Exposure (ND-PAE, which was previously known as Fetal Alcohol Effects (FAE) or Alcohol Related Neurodevelopmental Disorder (ARND)). The diagnosis of FAS means that a child was exposed to alcohol early enough in the gestation to result in changes to the developing face and skull as well as to the developing brain. The FAS diagnosis further specifies that the child will display reductions in stature, weight and head circumference; along with the classic findings of a smooth philtrum, thin upper lip and reduced distance between the medial and lateral canthi (inner and outer edges) of the eye. The last 3 features involve midline facial structures, the presence of which is highly correlated with underlying brain malformation and dysfunction. Reduced palpebral fissure length in particular has been shown to reflect a defect in forebrain development, and it is the forebrain which ultimately develops into the cerebral hemispheres (overall cognitive processes), hippocampus (learning and consolidation of memory), basal ganglia (time perception and cause-and-effect relationships), thalamus (efficient sensory processing), hypothalamus, (regulation and control of such bodily functions as temperature, hunger, thirst and rage), corpus callosum (integration between right and left hemispheres, e.g., processing visual and verbal input, emotions and logic), and frontal lobes (self-reflection, impulse control, planning, and working towards the completion of goals).

The great majority of children exposed to alcohol prenatally will not display the full features of FAS, but can manifest any degree of brain injury along the spectrum from mild to severe. If they have a confirmed history of prenatal exposure to alcohol and one or two of the three facial criteria (with or without growth deficiency) they can be diagnosed with pFAS. A third diagnostic category which has been proposed is Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure (ND-PAE, which is currently coded as ICD-10-CM F88 “other specified neurodevelopmental disorder”/neurodevelopmental disorder associated with prenatal alcohol exposure). For convenience, all of the previous diagnostic entities (FAS, pFAS and ND-PAE) can be subsumed under the “umbrella” term Fetal Alcohol Spectrum Disorder (FASD). Since we are not certain of the specific features present in your student; and the neurodevelopmental challenges are not distinguishable between the various groups, we will use the term FASD throughout the remainder of this response.

Although all children with FASD will be expected to have some combination of brain deficits, only rarely will a child have impairments in all domains of function. Not surprisingly, the principle problem areas for children with FASD characteristically involve the following functional domains:

•           planning, sequential processing, and awareness of time;
•           learning, memory, and generalization;
•           spatial concepts and spatial memory;
•           social awareness and adaptive behavior; and
•           motor skills, including oromotor control.

Deficits in these areas of brain function will often manifest as challenges with:

•           remembering rules and following multi-step tasks;
•           remembering appointments or assignments;
•           interpreting social cues;
•           observing appropriate interpersonal boundaries;
•           participating in group activities without disrupting them;
•           processing information quickly and accurately; and
•           behaving appropriately with same age peers;
or
•           behaving socially at an age-appropriate level.

Almost all students with FASD will have significant deficits in social and emotional development, and the discrepancy in social skill level between them and their peers will generally increase as they grow older. Despite having deficits in any or all of these areas, students with FASD do learn. Most of them develop basic academic skills during early elementary school and continue to develop their talents and master new skills in their areas of interest throughout their lives. They are often sociable, humorous and fun to be around. However, because most students with FASD have unusual patterns of ability (relative personal strengths and weaknesses), their behavior can seem unpredictable and confusing. It can be easy for adults and peers to lose patience if they do not know what to expect.

Students with FASD often present initially as being more capable and neuro-typical in their development than they actually are. They can acquire reasonably extensive vocabularies and may become competent at telling simple stories and anecdotes. Many have little shyness or fear of strangers, enjoy chatting with people they meet, and demonstrate a relative strength in the area of expressive language.

Only a small percentage of these children will score in the intellectual disability range at an early age. Most will score in the “below average” to “high average” range during their first years of elementary school. If they have repeated testing, their scores tend to decrease over time. Children with FASD typically do not develop complex, abstract thinking and problem-solving skills at the same rate, or to the same extent, as their peers. However, even when they get older, despite experiencing mild declines in their test scores, their cognitive and academic test scores often overestimate their level of functioning and underestimate their level of need for structure and supervision in daily life. Their deficits in social and emotional development make it increasingly difficult for them to adapt appropriately to increasingly complex environments where they are confronted with higher-level demands and expectations.

Students with FASD characteristically have difficulty generalizing and applying skills learned in a specific context to challenges they face in everyday life. Some have trouble with sequential processing, making it difficult to follow a routine unless they have a visual depiction of it in front of them. Sequential processing difficulties make it more difficult to develop a sense of time and to recognize cause-and-effect patterns. They do learn from experience, but often require considerable repetition.

Although they may learn to read and write and to communicate verbally with others; as they grow older, the concreteness and lack of variety or complexity in their communication becomes more apparent. It has been observed that many individuals with FASD seem not to demonstrate (or less reliably demonstrate) “good judgement” or “common sense.” Although these qualities are difficult to define operationally or measure, most observers can recognize the deficits when they are present. Even with explicit teaching, learning to exercise good judgement in their daily lives can be a formidable lifelong challenge.

Deficits in judgement often present as being more severe in individuals with FASD and no intellectual disability (ID) than in individuals with mild ID. Their lack of “good judgement” and “better than expected” superficial communication skills place students with FASD at increased risk of experiencing violence and trauma, being victimized, putting selves at risk of accidental injury or death (e.g., walking in front of traffic without checking), repeated involvement with the legal system, developing mental health conditions, and suicide.

Fortunately, there are resources available to help children with FAS, and many will be eligible for Regional Center Services in California. Most recommended interventions emphasize the need to provide a supportive, non-traumatizing environment which provides a safe place for them to grow and which recognizes and builds upon each student’s individual strengths. Having at least one adult they feel they can depend upon in any stressful situation is viewed as critical to their success. Additionally, identifying one or more “islands of competence” can be exceedingly helpful for them to experience success and develop a positive self-image. These elements can provide a basis upon which to customize a modified curriculum which builds upon the student’s own interests and strengths. Being exposed to supportive and patient adults will be key to achieving the highest attainable degree of success.

Even though there is no “cure” for the symptoms associated with FAS, early diagnosis followed by therapeutic intervention is crucial. Medications can play a role in addressing certain symptom complexes which are often seen in children with FAS. Unfortunately, the ADHD-like symptoms exhibited by students with FAS often do not respond well to stimulant preparations, which represent the mainstay of pharmacological treatment of symptoms in children with ADHD who were not exposed to alcohol prenatally. Non-stimulant preparations such as extended release guanfacine (trade name Intuniv), extended release clonidine (trade name Kapvay) and atomoxetine (trade name Strattera) are possible choices to help reduce their symptoms. A team approach is optimal, and should include a physician with experience in treating the symptoms often experienced by children with FAS. Although these physicians may be found in any community, they will often be associated with medical centers and teaching hospitals.

Thank you for your questions, and we hope your student receives the help he needs.

John L. Digges, MD, PhD, MPH, FAAP
Behavioral Pediatrician
Margaret Stivers, PhD
Clinical Psychologist
Diagnostic Center North
Fremont, California


  • New Problems in Students with Multiple Diagnoses - Part 1

Question:

Dear Marji,

I’m a speech and language pathologist and I’m concerned about one of my 8th grade students.  Although he has multiple diagnoses and a long history of difficulties, he is fully included in general education classes. However supporting him in his program is a continuous challenge. It seems as though each time we get effective supports in place, a previously minor problem flares up or a new problem emerges. Then new diagnoses are considered and the team reviews priorities and figures out how to proceed. I like this student a great deal and admire his courage and spirit in persisting with school despite the increasing obstacles he faces. I would like some help in understanding his latest behavioral difficulty, either in the context of his current diagnoses or a potential new one.

Diagnoses to Date:
This student has long-term diagnoses of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). Symptoms of anxiety and depression as well as obsessive-compulsive behaviors have also been noted. A couple of years ago, he started having vocal and motor tics which increased to the point of interfering with his school functioning and led to an additional diagnosis of Tourette’s syndrome. The tics are very loud, sometimes disruptive, and quite embarrassing to the student, which seems to have increased his anxiety.

The Latest Challenge:
As if all that is happening to this student isn’t enough, there is an additional behavior   that plagues him this year: whenever he can, he attempts to get access to female  shoes. This actually began when he was very young, 2-3 years old, when he appeared drawn to women’s shoes, desiring to touch and remove them. This urge seemed to subside and the behavior seemed minor in 6th and 7th grade. Since the beginning of 8th grade, the urges have increased to a point that the student cannot control them. His team has decided to refer to this behavior as “perseverative,” given that it has not been diagnosed as “obsessive compulsive.”  

He started by dropping items to gain access to shoes and touch them. Recently this escalated to removing shoes, even when the “victims” told him “NO, STOP.” This urge and lack of control has required the student to be escorted during transitions and remain in a “safe” environment, e.g. no temptation or access to females or their shoes during lunch and other breaks. He comes to the special education room with the goal of gradually returning to monitored lunch and breaks with the general education students.

The student is very aware of being observed, appears anxious, and sometimes requests the adult to remain close. He has also been noted to continuously glance around to see whether he is being watched.  On two occasions when he thought no adult was watching he approached young girls and attempted to touch their shoes.  When asked following one incident whether he knew the girl and could describe what she looked like, he said that he did not know her, nor what she looked like, only what kind of shoes she had on. The student acknowledges that he has these urges frequently and thinks about whether he can risk doing something without getting caught. He says that he does not feel aroused by female shows. But he appeared confused when asked if he has urges during PE, in the locker room, stating “What, it’s all boys.” He is aware that this

behavior potentially could get him trouble with the police needing to be involved. This appears to heighten his anxiety; however it is an urge that he cannot control all the time.

Are there any diagnoses that might account for the behavior -- either the conditions he is already diagnosed with or potential additional diagnoses?  If so, are there any implications for intervention?

Thanks for any information you can provide.

Teacher Who Wants to Help


Answer (Part 1):

Dear Teacher Who Wants to Help,

Your care, concern, and respect for your student shines through in your letter. Your student is lucky to have you as his teacher and you are probably learning a great deal from one another.

Despite the many other challenges your student experiences, his persistent attempts to gain access to female shoes is an immediate priority. This behavior has escalated to the point that he requires increased supervision and behavioral restrictions, resulting in substantial loss of opportunities to practice independence and social interaction. In addition, his behavior makes others uncomfortable, further decreasing his chances of developing positive social relationships. It could end up being more stigmatizing than his Tourette’s and, as you mentioned, it could even lead to trouble with the police. In short, it limits his current opportunities to participate in school and may jeopardize future opportunities.

Your letter provides a nice description of your student’s problematic behavior as well as some relevant historical information.  Unfortunately, without further assessment data, it is impossible to identify the underlying psychological factors or most appropriate diagnosis.  As a starting point, I will briefly describe the three diagnostic categories that seem to fit the described behavior and merit further exploration. This will be followed by suggested next steps, including the type of information to focus on getting and potential strategies for getting it.

Potential Diagnostic Categories

Your student’s persistent attempts to gain access to female shoes may represent:

  • Perseverative thoughts and repetitive behaviors associated with a highly specialized and narrow focus of interest.

This interpretation of female shoe-seeking behavior is based on the assumption that it is associated with his autism spectrum disorder (ASD). This explanation is consistent with the long-standing nature of his fixation on female’s shoes. The all-encompassing interests of individuals with autism can gradually shift or wax and wane over time, but often persist over many years.

However, overall it appears unlikely that your student’s behavior is a manifestation of his autism. The repetitive play with objects that is generally associated with autism appears to supply a level of sensory stimulation that the individual finds comforting. The choice of objects seems to be completely asocial; level of interest in a particular object is based on the sensory properties of the object itself rather than on an association between the object and the people, or type of people, who have used or worn the object. For instance, shoes might be selected on the basis of smooth texture or opportunity to tie and untie with shoe laces, but not on the basis of the gender of the wearer.

  • A compulsion to engage repeatedly in a particular pattern of behaviors.

This would likely be associated with an obsessive-compulsive condition or disorder (OCD).

Students with obsessive-compulsive behaviors have unwanted, anxiety-producing thoughts that they cannot get rid of (obsessions). They sometimes find that completing a particular sequence of behavior results in an immediate reduction in anxiety and feel compelled to repeat these behavioral rituals (compulsions), especially when feeling anxious. Sometimes there is a clear relationship between the anxiety (e.g., fear of encountering germs) and the behavior (e.g., repetitive hand-washing) and sometimes there is no logical relationship.  Adults (and your middle school student, if this applies to him) know that their behaviors are irrational, but this does not lessen the compulsion to engage in them.

OCD very commonly co-occurs with attention-deficit/ hyperactivity disorder (ADHD) and Tourette’s syndrome (TS).  In fact, they are so commonly diagnosed in the same individual that a number of scientists are actively seeking to identify a common genetic or neurological factor.  Therefore, an OCD pattern of behavior would be highly consistent with your student’s current diagnostic profile.

  • A fetish (from “fetico,” meaning obsessive fascination), a term for an unusual object that has become the target of persistent sexual interest.

If your student’s behavior is associated with a shoe fetish, the goal of his behavior is to obtain opportunities to touch or handle objects that evoke pleasurable sexual feelings.

Among the substantial minority of males who report having fetishes, female feet and shoes are two of the most, if not the most, common objects of attraction. Having a fetish is considered a type of paraphilia, or atypical sexual interest, but is not necessarily a disorder. However, it can be considered a disorder when the behavior associated with the fetish causes significant distress to self or others or interferes with daily functioning, which may be the case for your student.

Your student’s repetitive attempts to touch, hold, or acquire females’ shoes could be viewed as either an obsessive-compulsive pattern of behavior or an expression of a shoe fetish.. However, the explanations generated by these diagnoses involve very different assumptions about the reasons for this pattern of behavior. Selection of the best explanation requires accurate identification the function of the behavior. In other words, what needs are getting met, or what needs are your student trying to get met, when he engages in the behavior? Understanding of the function, or reason for the behavior is the key to figuring out which, if either, of these diagnostic categories offers the “best fit.” Further, determination of the function of the behavior will help generate feasible intervention strategies regardless of whether there is a corresponding diagnosis.

Next month in Answer, Part 2 I will discuss strategies for selecting the best diagnostic category and potential interventions.

Best wishes,
Marji Stivers