A Controlled Social Skills Training for Children With Fetal Alcohol Spectrum Disorders.

In 1996, the Institute of Medicine released a report containing broadly defined diagnostic criteria for fetal alcohol syndrome (FAS), partial FAS, alcohol-related birth defects (ARBD), and alcohol-related neurodevelopmental disorders (ARND). These diagnostic categories represent a continuum of effects and are subsumed under the term fetal alcohol spectrum disorders (FASD). It is estimated that in the United States, about 1 in 100 children born each year has FASD, resulting in substantial life-long impairments in development.

Three decades of research have documented a multitude of debilitating neurobehavioral effects following prenatal alcohol exposure. Much of this research has focused on overall intellectual functioning, and these general deficits have been revealed in both children with FAS and those with heavy prenatal alcohol exposure who do not exhibit all of the features to warrant a diagnosis of FAS. Other neurobehavioral deficits include inattention, hyperactivity, and poor language performance, as well as problems in memory and executive functioning. Alarmingly, these deficits also have been documented in the offspring of women who drank light to moderate amounts of alcohol.

As a consequence of the primary deficits described, children with FASD exhibit considerable social impairment. Problems understanding social cues, indiscriminant social behavior, and difficulty communicating in social contexts are reported. Both caregivers and teachers have rated children with prenatal exposure to alcohol as having fewer social skills than unexposed children, even after controlling for differences in cognitive functioning. Furthermore, studies of adolescents and adults with FASD have indicated that social skills deficits continue into adulthood.

Current research suggests that exposed children without mental retardation may be at the greatest risk for poor adaptation. In a study using parent report, alcohol-exposed children with less cognitive impairment were found to be more likely than children with mental retardation to exhibit lack of consideration for the rights and feelings of others, resistance to limits set by authority figures, and conduct problems suggestive of early delinquency. These findings are consistent with the increased rate of delinquency and school failure found in alcohol-exposed adolescents with higher IQs but without FAS. Given the high percentage of individuals with prenatal exposure to alcohol who have significant social problems as they grow older, it is important to begin promoting social problem solving and competence early in development.

Discussion

Children with FASD who participated in social skills training showed clear evidence of improvement in their knowledge of appropriate social behavior posttreatment, and this improvement was retained over a 3-month follow-up period. Moreover, according to parents, CFT was also effective in increasing social skills and decreasing problem behaviors in sample children. Overall, statistically significant differences between the CFT and the DTC groups immediately following treatment were found according to parent reports. It is also important that for the CFT group, social skills improved significantly from posttreatment to 3-month follow-up, suggesting that children were continuing to benefit from the intervention targeting social skills performance. Similar gains were reported for the children in the DTC group following treatment, suggesting that waiting 3 months for treatment was not detrimental. Study findings are consistent with those reported by Frankel and associates using CFT for children with and without ADHD. In contrast to previous results using CFT, teachers of children in the present sample reported no improvement for the CFT or the DTC group following treatment.

Failure to find statistically significant generalization of effects to the classroom merits some discussion. Close inspection of the baseline ratings by the teachers revealed that they tended to rate sample children as functioning within the average ranges in social skills and problem behaviors, suggesting that teachers did not perceive significant problems in social competence in sample children even at baseline. Frequency counts revealed that teachers rated only 19% of the sample as having social skills scores and only 34% as having behavior problems scores in the clinical range as defined in this study as between 1.5 standard deviations below or above the normative mean, respectively. The reason for this finding may be that teachers may focus less on child social skills than on behaviors related to successful classroom functioning.

Because this program was not designed to address those behaviors that are important for classroom success, teachers may not have observed changes in the behaviors targeted in this intervention. Indeed, the social skills targeted by CFT, such as trading information to establish common interests or peer group entry, are skills that are more likely to be enacted on the playground, periods when teachers may be less likely to be closely observing student behavior. Moreover, a positive association was found between child IQ and teacher-rated social skills, suggesting that teachers rated more intelligent children as making more significant social skills gains regardless of treatment condition.

Alternatively, the parents who participated in the CFT treatment may have overestimated changes in their children simply as a function of being involved in treatment. Although this is a plausible explanation for the difference seen between the parent and teacher outcomes, the fact that children in the treatment condition demonstrated a significant increase in their knowledge of the social rules of behavior that was retained over the follow-up period suggests that they did learn socially appropriate behaviors as a function of treatment.

Regarding the clinical significance of study findings, although the scores of the children in the CFT group met criteria for clinical equivalency with the normative sample following treatment (they were no longer scoring in the clinical range), their scores were still considerably different compared with the standardized mean of the normative sample, particularly with regard to problem behaviors. These findings are not surprising in light of the fact that children with FASD are characterized as having significant brain pathology that may restrict the degree of improvement they can achieve from this type of psychosocial intervention. Although we attempted to modify the treatment protocol to address primary neurocognitive deficits seen in children with FASD, it is possible that additional refinements of the intervention techniques will further enhance its efficacy with this population. Additionally, it may be useful to examine whether adjunctive therapies such as parent training or psychopharmacological interventions might improve treatment outcomes.

The conclusions of this study should be considered in the context of some methodological issues. Children were enrolled in the study in alternating sequence rather than randomized to condition. Nevertheless, no statistically significant differences between groups on any measured baseline variables were found, suggesting that there was no systematic bias in participant assignment. The lack of independent evaluation of child behaviors and failure to find concordance between parent and teacher ratings of child social performance represent limitations of the study, and future research would ideally measure social behaviors in more naturalistic settings such as during unstructured classroom time and on the playground.

In addition, some factors restrict our ability to generalize our study findings to larger populations of children with FASD. First, it was necessary to work only with children with verbal IQs of 70 or above because the treatment required that the children understand the instructions provided during the didactic portions of the sessions. This necessarily limited the generalizability of the study to some children with prenatal alcohol exposure.

In the future, further modifications of the protocol could be made to accommodate children functioning in the moderate to mild range of mental retardation, as social skills are extremely important for these children in order to foster more positive social adaptations. Second, the study sample was composed of volunteers who were actively seeking help for their children and who were highly motivated to participate, as evidenced by the low rate of study attrition. Although this may represent a potential limitation with regard to generalization to other children with FASD and their families, research shows that the children with FASD who have the best prognoses are those who are identified early, who come from stable supportive homes, and who receive intervention early in life. Given the requirement of parent involvement for the success of the present treatment, we would expect that it is those highly motivated families who would benefit most from this particular intervention.

This study represents the first controlled treatment for improving the social functioning of children with FASD. As such, it is a promising intervention for these children, who experience multiple failures in social interaction leading to poor peer choices and, for some, juvenile delinquency. However, the treatment was performed in a highly controlled university setting, and thus the next step in determining its effectiveness would be to test the treatment on children enrolling in more typical community-based programs.

Given the high rates of mental health problems among children with FASD, these children are likely to be seen for treatment in these community settings. Providing increased access to interventions that have been empirically demonstrated to be efficacious with this population would be a critical step toward reducing some of the devastating secondary disabilities faced by children with FASD and helping their families facilitate change.