The MILE Program: Helping with Math Achievement
Although Fetal Alcohol Syndrome and associated disorders were first
described in 1973 (Jones & Smith), only recently has attention
focused on finding effective intervention methods for affected children
with commonly observed developmental, learning and behavior problems.
Despite the significance of these problems for affected children,
parents and society, it was assumed that little could be done to
improve outcomes for this high-risk group. Both an inadequate understanding
of children’s specific cognitive deficits as well as lack
of data on the effects of intervention may have contributed to this
As part of a multi-site project funded by the Center for Disease
Control and Prevention (CDC) to stimulate intervention research
with alcohol-affected children, we developed a psychoeducational
program to address functional deficits in cognition and behavior
that are common in children with FASD. Although we could have targeted
a number of different problem areas, we chose to focus on the behavior
problems plus poor math learning and performance associated with
alcohol-related neurodevelopmental deficits.
The program consists of several parts: 1) learning readiness, 2)
parent empowerment, and 3) the Math Interactive Learning Experience
(MILE). Children who participated in the initial evaluation of this
program were recruited from the FAS Diagnostic Clinic at the Marcus
Institute at the Emory University School of Medicine in Atlanta.
They were between 3 and 10 years old, with an average age of 6 years,
and had a diagnosis of FAS or partial FAS. To be included in the
program children had to have an IQ higher than 50 and be living
in a stable home for at least six months.
The main elements of the learning readiness component were parent
training and any case management services (e.g., baby sitting, transportation,
medication management) needed to create the conditions under which
the child could benefit from appropriate instruction. To empower
caregivers, education was provided in the form of workshops directed
at two areas. The first involved caregiver advocacy training aimed
to educate them about prenatal alcohol and drug exposures, explain
how learning is affected, and inform them of the resources available
to support education and intervention. The goal was to empower caregivers
by improving their knowledge of their children’s development
and by illustrating how to be positive partners with their community
schools in their efforts to obtain needed resources for their children’s
instruction. The second workshop educated caregivers regarding appropriate
methods for management of children’s behavior and explained
the importance of age-appropriate behavioral regulation skills that
are needed to optimize learning experiences.
Eventually 61 families were included in the MILE intervention program.
All of the children had a comprehensive evaluation of their academic
skills and learning styles, and a learning plan was prepared. Half
were randomly placed in the MILE intervention and half were in a
Children in the MILE group received individualized one-on-one instruction
weekly for 6 weeks based on their learning plan. Instruction was
supported by a curriculum that used materials and methods designed
to compensate for both the cognitive “dys-control” and
the visual/spatial-based deficits in learning experienced by alcohol-affected
children. To help with executive function deficits (dys-control)
that interfere with learning and behavior relation, we used a meta-cognitive
control technique, called FAR (Focus and Plan, Act, Reflect)
during the instruction to teach the children to be more reflective
in their problem-solving skills. To help with visual/spatial learning,
we felt it was important that math concepts be visually
experienced through physical exploration of objects and
their relationships. For this reason we used manipulables (blocks,
rods, seeds) that can be directly handled to teach number concepts;
in addition, a vertical number line replaced the usual horizontal
number line to emphasize that as numbers increase in size they go
Along with the intensive, short-term, individual instruction of
the child, we provided training for caregivers and teachers to provide
an overall integrated educational program. To support children’s
learning and extend its influence, caretakers were provided with
training on methods for incorporating mathematical concepts into
free play and providing structured mathematical activities to their
children. To ensure that the intervention was consistent across
the environments, we offered coordination with the children’s
school systems regarding teaching methodologies, including consultations
with teachers, individualized educational plan development (as needed)
and in-service workshops to teachers interested in learning about
educating children who have alcohol-related neurodevelopmental compromise.
The goal was to provide a consistent method of instruction of mathematical
concepts across therapeutic, home and school environments.
After six weeks, families in MILE and in the contrast group were
again tested to see whether the intervention was helpful. They were
also tested six months later to record any longer-term effects of
the intervention on learning and behavior. Parents in both groups,
all of whom had received the workshop training, reported significantly
improved behavior in their children. This observation was confirmed
by the children’s teachers at the 6-month assessment. Improved
behavior was noted particularly in the areas of attention problems
and aggressive behavior. Those children who received the MILE intervention
had significant improvements in math performance on standardized
math tests and demonstrated improved handwriting. These gains were
also found six months later.
Since this first study, we have developed training programs for
teachers and are placing many of our
materials online to allow parents and instructors easier access.
We have carried out training in a number of special education and
tutoring programs in the Atlanta area, and will be evaluating the
results of this extension of the program in the coming year. The
MILE program demonstrates that, in the right circumstances, children
with FASD can demonstrate significant improvements in development
and behavior. When methods are developed or adapted to accommodate
the neurodevelopmental characteristics associated with prenatal
alcohol exposure as well as the impact of postnatal environment,
children are able to benefit significantly. We hope that having
the evidence that such improvement is possible will empower parents
and professionals to continue to advocate for early identification
and appropriate education and treatment for children prenatally
affected by alcohol.
References and Further Reading
Coles, CD, Kable, JA & Taddeo, E (2008, in
revision) Math Performance and Behavior Problems in Children Affected
by Prenatal Alcohol Exposure: Intervention and Follow-Up. Journal
of Developmental and Behavioral Pediatrics.
Jones KL, Smith DW. Recognition of the fetal
alcohol syndrome in early infancy. Lancet 1973; 2: 989.
Kable, JA, Coles, CD, & Taddeo, E Socio-Cognitive
Habilitation using the Math Interactive learning Experience (MILE)
Program for Alcohol-Affected Children. Alcohol: Clin Exp Res. 2007;
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A Medical Student Addresses FASD Among Rural
The University of Washington in Seattle has a strong commitment
to the care of underserved rural areas in our geographically large
region. As such, the university created a program to immerse medical
students in underserved Northwest communities during the summer
between their first and second years of school. The Rural/Underserved
Opportunities Program (R/UOP) is a month-long program during which
students work in a local family medicine clinic and complete a small
public health project based on the identified health needs of the
community. During the summer of 2006 I was sent to Plummer, Idaho
– a small town of 990 on the Coeur D’Alene Indian Reservation
of Northern Idaho. There the Benewah Medical Center, a clinic funded
by the Indian Health Service, serves both native and non-native
populations covering a large geographical region. The population
certainly qualified as both rural and underserved – as of
2000, one third of the patients were below 200% of the federal poverty
guidelines and approximately 56% had no insurance.
It didn’t take long to identify FASD prevention as a worthwhile
project in Plummer. Alcohol use is a widespread problem in the area.
Moreover, there is a high rate of teenagers and pre-teens engaging
in high-risk binge drinking and unprotected sex. It was almost commonplace
for 13 to 15 year olds to visit the clinic and test positive for
pregnancy while admitting recent substance abuse. These factors
greatly increase the likelihood of alcohol-exposed pregnancies,
reinforcing the need to implement prevention strategies.
Plummer is certainly not the only rural town dealing with the problems
of alcohol abuse and teenage pregnancy. What makes Plummer highly
qualified for FASD prevention is that it has an excellent clinic,
a well developed health department, and a fantastic, dedicated medical
staff with a true interest in the health of their community. The
physicians at Benewah Clinic were very open to anything that could
better serve their patient populations.
Changing patient health behavior is a difficult but vitally important
part of clinical practice. Physician-delivered interventions must
be quick, effective and easy to use. Motivational Interviewing (MI)
is an empirically supported way to change patient behavior using
brief interventions. MI is a patient-centered approach that empathetically
encourages the patient to come to his or her own conclusion about
behavior change. Open-ended questioning and summary statements are
used to develop discrepancies between the patient’s current
behaviors and their values or future goals. Resistance to change
is explored using techniques such as reflective listening, pros
and cons, and rules of importance (i.e., “On a scale of one
to ten, how important is stopping drinking to you?”). Exploring
resistance rather than confronting it avoids patient defensiveness
and supports autonomy. One of the best parts of MI is that it is
useful in modifying a wide variety of health-risk behaviors, making
the investment of time to learn the technique worthwhile for providers.
Since large portions of time in primary care practice are spent
attempting to change patient behavior, offering MI as a validated
tool makes it an easy sell to providers.
After a literature review and consultation with experts in the
field I decided that an MI-based intervention would be most suited
for FASD prevention in this community. Inspired by the work of Project
CHOICES, I decided to take the previously validated approach
of targeting two distinct groups: pregnant women and women who drink
while using ineffective means of contraception. I synthesized techniques
used in previously successful research studies into separate provider-delivered
interventions for each group. I then organized them into an easy-to-follow
flowchart (Figure 1, Figure
2) with examples of possible phrases to use. Community health
providers from the Benewah clinic and neighboring community health
center attended a 30-minute PowerPoint presentation in which I introduced
FASD, explained MI techniques and distributed the flowcharts to
each provider. In addition, I ordered updated and appropriate FASD
patient education and community awareness materials from the Centers
for Disease Control (CDC).
R/UOP participants doing community health projects have no human-subjects
approval and therefore are not allowed to collect data of any sort.
As such, I can’t document if the intervention is working or
even if all of the doctors are using the approach. However, I can
report that the providers in Plummer recognized alcohol-exposed
pregnancies as a large problem and the information about FASD prevention
and Motivational Interviewing was well-received. The project has
also been given more attention than I thought it would – it
was awarded the University Of Washington School Of Medicine’s
Liu Bie Ju Endowed Fellowship for Excellence in Women’s Health,
presented at the Western Student Medical Research Forum, and has
allowed me to write this article in a well-respected FASD newsletter.
Meanwhile, Dr. Mary Barinaga – my then clinic preceptor in
Plummer and now friend and mentor – assures me that she not
only uses MI, but looks at contraceptive counseling a little differently.
At the very least I’d like to think that FASD prevention is
a little closer to the front of a few people’s minds –
my own included.
Emmons, K., & Rollnick, S. (2001). Motivational
interviewing in health care settings: Opportunities and limitations.
American Journal of Preventative Medicine, 20(1), 68-74.
Handmaker, N., & Wilbourne, M. (2001). Motivational
interventions in prenatal clinics. Alcohol Research and Health,
Project CHOICES Intervention Research Group.
(2003). Reducing the risk of alcohol-exposed pregnancies: A study
of a motivational intervention in community settings. Pediatrics,
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Canadians in Planning for Adult FASD Assessment
As described in the September
2007 issue of the Iceberg, there is a recognized need
for adult diagnosis of FASD, as this population has been underserved.
This was one of the reasons that I opened my clinic to assess adults
and adolescents in the Seattle area. There are other practitioners
in the United States that are offering assessment services for adults
and late adolescents. However, all of these services have been developed
in an ad hoc manner, establishing clinics in relative isolation.
The Public Health Agency of Canada has somewhat different plans.
They are attempting to develop widespread diagnostic clinics that
use the same procedures from site to site, allowing for a much more
standardized diagnostic approach. Thus, on November 18, 2008, experts
in the field of assessment and diagnosis of children and adolescents
and adults across Canada convened for a two-day conference in Edmonton,
Alberta, to discuss how to develop standardized diagnostic clinics
for adults suspected of FASD. I was honored to be asked to participate
in the discussions as one of the few practitioners in the United
States currently doing this kind of work.
On the first day of the meetings we discussed the experiences of
the clinics in Canada currently diagnosing adults. Several questions
were raised during this discussion:
- Does the capacity exist to add adult assessments to already
established diagnostic clinics seeing children and adolescents?
- Is it practical to integrate the assessment services for adults
into the programs for the younger clients or should they be established
as separate clinics?
- Would the diagnostic team need to be different than it is for
- What professionals would be essential for an adult diagnosis?
- Would a psychologist/neuropsychologist and a medical doctor
be all that is needed, or would we also need an occupational therapist,
physical therapist and speech therapist?
- Would there need to be additional experts, such as those involved
with the legal system or vocational counselors or others?
- Does a centralized team approach where the client is seen by
all members of the team at the same time seem feasible, or would
a more sequential approach where the client sees a series of practitioners
over the course of weeks (based on the assessment needs for each
individual case) be more appropriate?
We grappled with these interesting questions, and discussed pros
and cons for each method. Because the ultimate goal is to develop
a system-wide approach to the diagnosis of adults, standardization
of procedures is very important so that data from one site is consistent
with data from other sites. To this end, Dr. Sterling Clarren discussed
the development of standardized intake and assessment forms that
could then be entered into a centralized database both for future
research purposes and to establish each service’s efficacy.
This would be an extremely valuable addition to the field. This
approach has been very effective with the Parent-Child Assistance
Program (PCAP), originally developed at the University of Washington
in Seattle and now spawned across the U.S. and Canada. They have
established a centralized database where all data from the PCAP
process is available. From this database, they have been able to
establish the effectiveness of the services provided and use this
data to justify to government agencies that the program is cost-effective
and provides high quality services. Any governmentally organized
services for the diagnosis of adults with FASD needs to show similar
effectiveness in order to justify the money spent.
On the second day of the meetings, participants broke up into three
smaller discussion groups. The first group was oriented toward individuals
and groups who are considering or are already in the process of
developing diagnostic clinics. This group discussed the practicalities
of establishing clinics, development of teams of professionals,
and the resources that are needed. The second group worked with
existing clinics within the Alberta province to discuss how to create
common data collection methods and move toward commonality in service
provision. The third group consisted of practitioners and policymakers
across Canada and the U.S. to discuss the policy issues that are
involved in such a large systemic undertaking.
The meetings were very interesting and covered many good ideas.
While no final consensus was developed at the end of the meeting,
we met the meeting’s goal of beginning to develop a diagnostic
process that is consistent across all sites. I wish Alberta and
all of Canada the best in developing this process as it will have
implications not only in their country but here in the U.S. and
across the world.
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