Elsevier

Alcohol

Volume 41, Issue 6, September 2007, Pages 403-414
Alcohol

Article
Language and literacy outcomes from a pilot intervention study for children with fetal alcohol spectrum disorders in South Africa

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Abstract

This pilot study investigated the efficacy of a classroom language and literacy intervention in children with fetal alcohol spectrum disorders (FASD) in the Western Cape Province of South Africa. The study forms part of a larger, ongoing study that includes metacognitive and family support interventions in addition to language and literacy training (LLT). For the LLT study, 65 nine-year-old children identified as either FASD or not prenatally exposed to alcohol, were recruited. Forty children with FASD were randomly assigned to either a LLT intervention group or FASD control group (FASD-C). Twenty-five nonalcohol-exposed children were randomly selected as nonexposed controls (NONEXP-C). Prior to intervention and after nine school-term months of treatment, general scholastic tests, teacher and parent questionnaires, classroom observations and specific language and literacy tests were administered to the participants. The nine months assessment reflects the midpoint and the first assessment stage of the overall study. At initial diagnosis and prior to commencement of the interventions, participants with FASD were significantly weaker than NONEXP-C children in reading, spelling, addition, subtraction, phonological awareness, and other tests of early literacy. Teachers rated a range of adaptive behaviors of children with FASD as significantly worse than NONEXP-C. Mean scholastic and language and literacy scores for all groups showed improvement over baseline scores after 9 months of intervention. The mean test scores of children with FASD remained lower than those of NONEXP-C. Comparison of mean baseline to postintervention score changes between the LLT, FASD-C, and NONEXP-C groups revealed that although there were no significant gains by the LLT intervention group over control groups on the general scholastic assessment battery, significantly greater improvements occurred in the LLT intervention group compared to the FASD-C group in specific categories of language and early literacy. These categories were syllable manipulation, letter sound knowledge, written letters, word reading and nonword reading, and spelling. In spite of cognitive and classroom behavioral difficulties, children with FASD from a vulnerable environment demonstrated significant cognitive improvements in specific areas targeted by classroom interventions. To our knowledge, this is the first report of a systematic classroom intervention and resultant cognitive response in children with FASD.

Introduction

The term fetal alcohol spectrum disorder (FASD) encompasses a continuum of mild to severe physical and neurobehavioral effects in children exposed to alcohol in the prenatal period. Although considerable attention has been devoted to delineating the neurobehavioral functioning of children with FASD, relatively little is known about effective interventions for learning and behavioral problems in these children. In 1996, a fetal alcohol syndrome (FAS) study committee of the Institute of Medicine (IOM) recommended the evaluation of effectiveness of educational interventions on children prenatally exposed to alcohol (Stratton et al., 1996). Even before the IOM report, the need for developing intervention programs for alcohol-affected children had been recognized (Carmichael-Olson et al., 1992), yet few systematic outcomes studies of intervention programs exist. Studies have been reported by O'Connor et al., 2006, Premji et al., 2007, and Riley et al. (2003).

The lack of research on effective interventions to ameliorate behavioral and learning problems in children with FASD can be attributed to a number of factors. First, despite extensive literature on the neurobehavioral functioning of children with FASD (Connor et al., 2000, Kodituwakku et al., 2001, Mattson et al., 1999, Mattson and Riley, 1998, Riley and McGee, 2005), there is no consensus yet among researchers on their cognitive and neurobehavioral phenotype. Designing effective treatment for a given disorder requires specifying central (core) and peripheral deficits and strengths associated with that disorder. Second, researchers with a specialty in intervention have not had access to large groups of well-diagnosed children within the FASD continuum, thus preventing the design of systematic outcome studies that use rigorous scientific methodology. Third, there has been minimal exchange of ideas between educators, clinicians, and basic scientists with regard to development of effective intervention programs.

Although the core deficits in FASD have not been clearly delineated, sufficient information exists about areas of deficit (general intelligence, language, executive function, memory, attention, gross and fine motor skills) and relative potential strengths, to provide a base for development of appropriate interventions (Kalberg and Buckley, 2006). In studies conducted in South Africa (May et al., 2000, May et al., 2007, Viljoen et al., 2005), we also found that children with FAS were impaired not only in verbal and nonverbal IQ, but also in tasks that measured fundamental language skills such as grammar comprehension and memory (Adnams et al., 2001, Kodituwakku et al., 2006).

An intervention study has the potential to shed light on the cognitive phenotype of children with FASD. Interventions aimed at certain deficits may effect improvements in other deficits, thus helping to identify primary (core) and secondary deficits. Identification of the mechanisms underlying neurobehavioral change in children with FASD should eventually lead to the development of effective intervention methods (Kalberg and Buckley, 2006).

FASD constitutes a significant public health problem in high-risk populations in South Africa. Previous epidemiology studies have indicated a high prevalence of FASD in school children aged 5–9 years in this high-risk region in the Western Cape (May et al., 2000, May et al., 2007, Viljoen et al., 2005). This has yielded a large cohort of children diagnosed within the FASD continuum, as well as controls from a similar ethnic, socioeconomic, language, and educational background. Previous neurobehavioral studies in this region demonstrated that besides deficits in verbal and nonverbal intelligence, children with FASD in this community have fine motor skills, visuospatial and behavior problems compared to controls (Adnams et al., 2001, May et al., 2007, Viljoen et al., 2005).

It is known that deficits in academic and adaptive skills are associated with impoverished living conditions (Barnett, 1998, Bradley et al., 2001, Liddell and Rae, 2001, McLoyd, 1990). Poverty, low maternal education, and depression are all contributory factors that have prevailed in the cohort studied here. The children identified in these studies are Colored (mixed ancestry of Black African, White, and Malaysian decent) and have inherited an educational system that continues to suffer from the legacy of South Africa's apartheid era. More recent changes in the country's national education policy, consistent with the international trend toward inclusive education, provide for inclusion of children with mild intellectual and learning disabilities within the mainstream system (South African Government Department of Education, 2001). Most children with FASD fall in the category of mild intellectual disability and remain in mainstream education in South Africa, in spite of the fact that they may have significantly disabling behavioral, attentional, and executive functioning problems (Kodituwakku et al., 2001). The burden of FASD in school-aged South African children thus falls heavily on a poorly resourced state education system. Given the high prevalence and the sociopolitical context of FASD in the Western Cape region, it is not only a research, but also an ethical imperative to address systematic interventions aimed at amelioration of learning and behavior disabilities in children identified with FASD. A previous pilot intervention study undertaken in this community, demonstrated improvements in self-regulation and behavior in children with FASD (Riley et al., 2003).

South African school education is reliant on the medium of spoken language for most instruction and this is likely to exacerbate primary deficits of language in children with FASD. Spoken language can be analysed into large speech units (words and syllables e.g., “pram”), intermediate speech units (onsets, /pr-am/ and rimes, /pr-am/), and small speech units (phonemes e.g., /p-r-a-m/). Phonological awareness refers to a person's awareness that language has a sound structure. It is the ability, aside from ascribing meaning, to recognize and manipulate words into smaller units such as syllable, intrasyllabic structures, and phonemic segments which can be blended, deleted, and inserted. Speech, reading, and phonological awareness all share the same speech processing system. Language deficits may undermine the complex processes involved in literacy acquisition and children presenting with deficits in vocabulary, phonology, and expressive language have difficulty learning to read, spell and, engage in creative writing activities. There is now an established causal link between early phonological awareness and reading achievement (Stahl and Murray, 1994) and there is a strong body of evidence that phonological training not only results in improved awareness, but also in better reading and spelling skills in at-risk children (Lundberg et al., 1988, Ball and Blachman, 1991). Wimmer et al. (1991), reported that the predictive value of phonological awareness before instruction in first graders was independent of IQ and initial differences in letter knowledge and reading ability. Although phonological awareness is crucial to literacy development, successful reading outcomes depend on the learners' ability to link their phonological awareness skills to letter knowledge and reading experience. This is referred to as the phonological linkage hypothesis (Hatcher et al., 1997).

Since many of the mental representations involved in literacy are the same as those involved in receptive and expressive language activities, it is necessary to tailor a language and literacy program to address both the language and literacy deficits in children. Many programs implementing phonological awareness training to children at risk for reading difficulties have been developed over the past two decades. Few such programs have been developed and tested in the South African context. The multisensory phonological awareness and letter knowledge program was devised by Nadler-Nir (1997), who conducted a study on disadvantaged first graders in the Western Cape Province of South Africa. The intervention focused on improving various components of phonological awareness, including segmentation, blending, manipulation, and letter knowledge. Results of the study indicated that the program was highly effective in improving phonological awareness, letter knowledge, reading, and spelling skills.

Although there are many tests of phonological awareness, the use of a variety of measures to tap both simple and compound phonological awareness skills is desirable. The phonological awareness tests used in this study (Table 1) conform to a range of levels of difficulty from the most basic, or lower order, to complex higher order phoneme manipulation.

The overall study was undertaken to evaluate the efficacy of three intervention methods on children with FASD from a community in South Africa. The aim of this study focuses on outcomes of one of the interventions. Given the background of language deficits and thus risk for literacy disability in children with FASD, the specific aim was to determine the degree to which a classroom language and literacy intervention program improved academic skills in children exposed to high levels of alcohol. We hypothesize that the core, or fixed deficit in children with FASD is ameliorable to a degree yet unknown, and that children with FASD can improve in specific academic skills after targeted interventions.

Section snippets

Participants

The participants recruited in the larger intervention study were 105 third grade children (53 boys and 51 girls) from 10 schools in a high-risk region in the Western Cape. For the present study, 40 of the above children with FASD and 25 nonexposed controls (NONEXP-C) participated. The children with FASD were assigned to language and literacy training (LLT) intervention (20) and FASD controls (FASD-C; 20). The participants were similar in age, socioeconomic status, and first language

Participant attrition

At postintervention assessment, four children were lost to the study (two of 20 FASD children in the LLT group and two of 25 NONEXP-C). Three of these children moved away from the area, and the parents of the fourth control child withdrew consent. The two FASD-C children who did not meet diagnostic criteria for FAS, PFAS, or Deferred were excluded from the statistical analysis in order that this report reflected only those participants with a diagnosis on the more severe spectrum of FASD. The

Discussion

The study results confirm the hypothesis that children with FASD can improve in specific skills in response to targeted cognitive interventions. Significant gains over FASD controls were made following administration of a program that targeted literacy and linguistic skills. This outcome is consistent with other intervention studies in environmentally and intellectually vulnerable but nonalcohol-exposed children at risk for reading and literacy disabilities (Conners et al., 2006, Nadler-Nir,

Acknowledgments

Loretta Hendricks for efficient fieldwork and support of participating families and children; the participating Wellington children, their families and schools. Petra Engelbrecht Ph.D., University of Stellenbosch; David Buckley, The University of New Mexico, Faye Calhoun Ph.D. and Ken Warren, Ph.D., NIAAA for their ongoing encouragement and support.

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    This study was supported by National Institute on Alcoholism and Alcohol Abuse grants RO1 AA09440 and R01 AA 11685 (PI: May), by the Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CIFASD), grant U01 AA 014786 (PI: May) and the NIH Office of Research on Minority Health and Disparities.

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