Socio-cognitive Habilitation Using the Math
Interactive Learning Experience Program for
Julie A. Kable, Claire D. Coles, and Elles Taddeo
Background: Fetal alcohol syndrome (FAS) has been recognized as a disabling condition with a
significant impact on the neurobehavioral functioning of affected individuals, including cognition,
behavior, and academic functioning, but little research has been performed on targeted interventions
for these children.
Methods: A socio-cognitive habilitative program focused on improving behavior and math
functioning in children 3 to 10 years of age (n561) was developed and evaluated. The intervention
provided parental instruction on FAS, advocacy, and behavioral regulation via workshops and
interactive math tutoring with children. All families received parental instruction and were then ran-
domly assigned to either the math instruction or standard psychoeducational care groups.
Results: Satisfaction with workshops was very high, with over 90% agreeing that trainers were
knowledgeable and materials easy to understand and helpful. Significant gains in knowledge were
found for information provided in the instructional groups. At posttesting, caregivers reported fewer
problem behaviors on the Achenbach Child Behavior Checklist, Internalizing Problem Behavior,
Externalizing Problem Behavior, and Total Problem Behavior summary scales. After 5 months, both
groups of children demonstrated gains in math knowledge but significantly higher gains were found
in the group receiving direct math instruction. The math treatment group was also more likely to
demonstrate a gain of over 1 standard deviation on any of the 4 math outcome measures used.
Conclusions: These findings suggest that parents of children with fetal alcohol spectrum disorders
(FAS(D)) benefit from instruction in understanding their child’s alcohol-related neurological damage
and strategies to provide positive behavioral supports and that targeted psychoeducational programs
may be able to remediate some of the math deficits associated with prenatal alcohol exposure.
Key Words: Prenatal Alcohol, Intervention, Math, Parent Training.
lic more than 30 years ago (Jones and Smith, 1973). Since
that time, there has been extensive study, both in animal
models and in clinical studies, of the teratogenic effects of
prenatal alcohol exposure on the development of off-
spring, confirming original observations and extending
our understanding of this disorder. While many debates
continue regarding proper diagnostic methods and the
brought to the attention of professionals and the pub-
ALCOHOLSYNDROME (FAS) was
nature of a ‘‘behavioral phenotype,’’ there is no longer
any question that FAS is a disabling condition and that
this condition has significant long-term consequences both
for affected individuals and for their families. Initially,
because of a teratogenic perspective, much empirical
research was focused on the neurocognitive consequences
of exposure, with limited attention to the clinical and
social outcomes. However, with better identification of
this disorder, parents and clinicians have become increas-
ingly aware of the behavioral, adaptive, and social
consequences and have begun to ask for appropriate meth-
ods for treatment and habilitation of affected individuals
(Coles, 1998; DeVries, 1999; Weinberg, 1997). In a survey
of clinically referred individuals, Streissguth et al. (2004)
found that the odds of escaping adverse life outcomes,
such as psychiatric disorders, trouble with the law, and
school disruption, were dramatically increased when alco-
hol-affected individuals were diagnosed early and had
stable living environments.
Unfortunately, the growing demand for specific and
appropriate treatment for alcohol-affected individuals,
while justified, has been difficult to meet. Working within
existing systems can be problematic because affected
From the Marcus Institute, an Affiliate of Kennedy Krieger Institute
at Emory University, Atlanta, Georgia (JAK, CDC, ET); the Depart-
ment of Pediatrics at Emory University School of Medicine, Atlanta,
Georgia (CDC, JAK); and the Department of Psychiatry and Behavioral
Sciences at Emory University School of Medicine, Atlanta, Georgia
Received for publication December 11, 2006; accepted April 2, 2007.
This research was carried out by with the support of the Centers for
Disease Control and Prevention (CDC) Cooperative agreement U84-
Reprint requests: Julie A. Kable, PhD, Marcus Institute, 1920 Briar-
cliffRoad, Atlanta,GA 30329;
Copyright r 2007 by the Research Society on Alcoholism.
Alcohol Clin Exp Res, Vol 31, No 8, 2007: pp 1425–1434
ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH
Vol. 31, No. 8
children and adolescents often do not fit comfortably into
existing treatment and educational categories (Coles and
Platzman, 1992) or have behavioral and self-regulation
problems in addition to cognitive disabilities or specific
Only recently have efforts been made to develop targeted
interventions for alcohol-affected children. Animal mod-
els have used antioxidants given perinatally and forced
motor learning experiences to ameliorate the impact of
prenatal alcohol exposure (Guerri et al., 2005). These
models provide support for habilitative efforts among
infants and children who were prenatally exposed to alco-
hol. Two promising interventions have been piloted in
South Africa. The first involved using a metacognitive
intervention entitled cognitive control therapy to improve
behavioral and school functioning, and trends toward
improvement were found with a sample of 5 children
(Adnams, 2002; Stromland et al., 2005) and is being
further evaluated using a sample of 101 children (Kalberg
and Buckley, 2007). The second involved a project
designed to build basic literacy skills where alcohol-
exposed children demonstrated greater gains in response
to intervention than did non-alcohol–exposed controls
(Adnams et al., 2006; Stromland et al., 2005).
More focal interventions with alcohol-affected children
a social skills training program
children with a history of prenatal alcohol exposure, find-
ing improvement in social skills knowledge when those
receiving treatment were compared with a delayed treat-
ment control group. In addition, reductions in behavior
problems were reported by parents as a function of the
intervention. Gains, however, did not generalize to the
school environment but the authors note that the teachers
did not see as many disturbances in social functioning at
baseline as did parents and that teacher perception of gains
in social skills over the course of the intervention were
positively related to the child’s IQ regardless of the inter-
vention group. They also posited that the lack of positive
gains on the teacher measure may be the result of teachers
being more focused on social behaviors related to class-
room functioning and less focused on the social behaviors
targeted by the intervention, which are more likely to be
expressed during free play or recess periods. In a different
set of studies, using a virtual reality teaching format, chil-
dren, ages 4 to 9, with FAS and FASD were found to
improve in their knowledge of personal safety, including
fire safety and street crossing. The children also demon-
strated generalization from the computer environment to
the ‘‘real world,’’ suggesting that affected children benefit
from instructional programs where the presentation of the
information is tailored to their learning needs (Coles et al.,
in press; Padgett et al., 2006).
In designing appropriate and practical services for this
group of children as for any other group, the first challenge
is to identify and describe the specific needs that will be the
target for intervention. The current study focuses on
deficits in math achievement. Functional deficits in math
cognitions and achievement are reported consistently
2002) through adulthood (Kopera-Frye et al., 1996) and
relative deficits in this area have been a robust finding
in children with prenatal alcohol exposure (Coles et al.,
1997, 1991; Goldschmidt et al., 1996; Howell et al., 2006;
Jacobson, 1999; Jacobson et al., 2003; Kable et al., 2003;
Mattson et al., 1998; Spohr and Steinhausen, 1984;
Streissguth et al., 1994, 1993, 1991). Poor myelinization,
particularly in areas impacting the cross-hemispheric
transfer of information (Ma et al., 2005; Riley et al., 1995;
Wozniak et al., 2006), and altered development and func-
tioning of parietal regions of the brain (Riikonen et al.,
1999) that are involved in the visual-spatial processing of
information (Dehaene, 1997; Geary, 1993) have been
posited as potential reasons for the relative deficit in math
seen in alcohol-affected children.
Understanding math disabilities in general can provide
an insight into the math deficits found in alcohol-affected
children. Geary (1994, 1993) has identified a visuo-spatially
based deficit as 1 of the 3 subtypes of developmental
dyscalculia or math disability. He suggests that children
who have difficulties in visual processing misinterpret spa-
tial symbols and show deficits in the spatial representation
that underlie fundamental math concepts. Ashcraft (1995)
further argues that math disability results from working
memory deficits but acknowledges that these problems
may be related. Swanson (2006) found that changes in
working memory skills over time in children were related
to incremental changes in mathematical problem-solving
performance and concluded that working memory plays a
critical role in integrating information needed for mathe-
matical problem solving. As both working memory
(Kodituwakku et al., 1995; Rasmussen, 2005) and visual-
spatial processing (Aronson and Hagberg, 1998; Aronson
et al., 1985; Carmichael-Olson et al., 1998; Coles et al.,
2002; Kaemingk and Paquette, 1999; Mattson and
Roebuck, 2002; Mattson et al., 2006; Morse et al., 1992;
Platzman et al., 2000; Spohr et al., 1993; Steinhausen et al.,
1982; Ueckerer and Nadel, 1996) have been found to be
compromised in children who are alcohol affected, their
deficits in math skills are not surprising and are consistent
with other clinical groups with similar brain damage [i.e.,
nonverbal learning disability (Rourke, 1995), William’s
syndrome (Harris, 1995), Gerstmann’s syndrome (Benton,
1992; Lebrun, 2005)].
In developing a model for a habilitative math interven-
tion program for alcohol-affected children, we also looked
to previous work in cognitive rehabilitation for guidance.
The literature on interventions with children who have
brain damage suggests that to alter cognitive functioning
effectively, interventions must be contextualized within
the environment of the individual (Ylvisaker, 1998). His-
torically, interventions designed to treat the underlying
KABLE ET AL.
cognitive structures of a task have shown little gener-
alization beyond the task parameters specified in the
intervention. Such findings suggest that in developing
interventions to habilitate children who have brain dam-
age from prenatal alcohol exposure, one must select a
functional skill that is impacted by the brain damage and
construct an intervention that will remediate the deficits
(i.e., visual-spatial processing and working memory) with-
in the context of that functional skill. As such, we opted to
work on math skills directly while accommodating the
underlying problems with neurocognition rather than
attempting to build the neurocognitive skills and hope the
improvements generalized to math tasks.
Accordingly, we developed and evaluated a psycho-
educational program for alcohol-affected children that
provided learning strategies to compensate for core
deficits in learning ability, working memory, and poor
visual-spatial skills that were manifested as relative deficits
in math and premath skills. The program targeted children
between the ages of 3 and 10 years and provided a
comprehensive intervention across several levels of func-
tioning. These levels included intensive, short-term,
individual instruction of the child as well as training for
caregivers and teachers. To support children’s learning
and extend its influence, caretakers were provided with
training on methods for incorporating mathematical con-
cepts into free play, providing structured mathematical
activities to their child, and facilitating completion of
mathematical homework (if age appropriate). To ensure
that the intervention was consistent across the envi-
ronments, coordination with the child’s school system
regarding teaching methodologies was offered, including
consultations with teachers, individualized educational
plan development as needed, and in-service workshops
for teachers interested inlearning about educatingchildren
who have alcohol-related neurodevelopmental compro-
mise. The goal was to provide a consistent method of
instruction of mathematical concepts across therapeutic,
home, and school environments.
Although a specific intervention focusing on math skills
and the precursors to math may be fruitful in addressing a
specific weakness in alcohol-affected children, it would be
naı¨ve to ignore the other problems that present with a clin-
ically referred group. Most clinically referred children
have problematic medical and caregiving histories, as well
as socio-economic problems and behavior problems that
must be taken into account in designing intervention
studies (Kable and Coles, 2004a; Kalberg and Buckley,
2007). Behavioral regulation and attentional problems
are commonly reported by parents and professionals
(Kodituwakku et al., 1995; Kopera-Frye et al., 1997;
Nanson and Hiscock, 1990; Oesterheld and Wilson, 1997)
and such behaviors may interfere with learning. In addi-
tion, caregiving disruptions of various kinds are the norm
ratherthan the exception whendealingwith young, alcohol-
affected children. Finally, many children with prenatal
alcohol exposure are in foster care or have families with
limited economic and social resources. In designing our
approach to intervention, we tried to take into account the
contribution of these other factors and to incorporate
needed support to allow the child to achieve readiness to
learn. While there is some question about the specificity of
these medical, economic, and social factors to prenatal
alcohol exposure, their impact on development and behav-
ior is inarguable.
The intervention program, as developed, had the follow-
ing components: (1) caregiver education, provided in the
form of workshops to improve knowledge about the
teratogenic effects of prenatal alcohol exposure particularly
as it affects learning, the resources available to support
education and intervention, and appropriate methods for
management of children’s behavior; (2) support for learn-
ing readiness including case management services and
psychiatric consultations for those children who needed
support with their medical regimens or with identifying
therapeutic interventions needed to facilitate their socio-
emotional adjustment; and (3) focused math intervention
provided to half of the participants. We hypothesized that
the intervention program would have the following
1. Parents participating in educational workshops would
increase their knowledge of these issues.
2. Parents would find the workshops beneficial.
3. Parents would report improved behavioral outcomes in
4. Children from families randomly assigned to a targeted
habilitative program to facilitate their math develop-
ment would demonstrate greater maturation in this
skill compared with children who received standard
MATERIALS AND METHODS
Children between the ages of 3 and 10 years were recruited from
the Atlanta metropolitan area. The majority of the children were
recruited from a multidisciplinary FAS diagnostic clinic. Children
qualifying for the study were identified by clinicians from medical
records under an HIPAA partial waiver. Their families were mailed
information about the study and asked to volunteer to participate.
Community recruitment consisted of ads placed in local papers,
mailings to school systems, pediatrician and developmental pediatri-
cians, and talks at local meetings by study staff. To participate,
children were required to have been with their current caregiver for
at least 6 months before enrollment and projected to remain with this
caregiver for the next 6 months. Participants were excluded if cogni-
tive functioning was in the moderately intellectually deficient range
or below (i.e., IQo50) or if they had other mental health problems
that may have interfered with their ability to benefit from academic
instruction (i.e., autism). Children who had a dual diagnosis of
attention-deficit disorder were not excluded from participation.
After an initial screening, qualifying guardians completed a con-
sent procedure approved by the Human Subjects Committee of the
Emory University School of Medicine and signed an informed con-
sent document for their own and their children’s participation. All
THE MILE PROGRAM FOR ALCOHOL-AFFECTED CHILDREN
activities were carried out at the Marcus Institute, a familiar location
for the majority of the participants. All participants were required to
have a clinical diagnosis of FAS or partial FAS or significant levels
of alcohol-related dysmorphology to participate in the study using
the Institute of Medicine criteria established for making a clinical
diagnosis of FAS and/or partial FAS (Stratton et al., 1996). All the
children received a physical examination using a standard pediatric
dysmorphia checklist (Fernhoff et al., 1980) by a pediatric geneticist
with specialized training in assessing alcohol-related dysmorphic
features. This checklist is a modification of the usual ‘‘genetics’’
checklist where characteristics associated with the disorder are listed
and weighted based on their saliency for the diagnosis (e.g., hypo-
plastic philtrum is a ‘‘3’’). The 30 weighed items are summed to yield
a dysmorphia index or ‘‘pedscore.’’ Scores 410 are assumed to
indicate alcohol-related dysmorphology. The checklist has been eval-
uated repeatedly as part of longitudinal research studies from birth
to adolescence with individuals prenatally exposed to alcohol receiv-
ing higher total scores in comparison with nonexposed controls
(Coles et al., 1997, 1991).
Children also received a neurodevelopmental evaluation to assist
with their educational planning. Testing was conducted before
participation in the group workshops and was done over 2 days,
requiring approximately 4 to 5 hours to complete. Caregivers com-
pleted questionnaires during this time as well. Testing on the first day
consisted of assessments of (1) cognitive functioning using the Dif-
ferential Ability Scales (Elliot, 1983); (2) graphomotor functioning
using the Beery–Buktenica Developmental Test of Visual Motor
Integration (Beery and Buktenica, 1997); and (3) visual attention
skillsusing theNepsy (Korkman et al., 1997).Assessments conducted
on the second day included the pretest math measures.
Readiness to Learn. To establish ‘‘readiness to learn’’ in our
participants, case management and psychiatric consultation were
provided as needed. Caregivers of participants were also required to
attend 2 training workshops. The first workshop educated parents
about FAS and provided information about special education and
methods for advocating for their children with school systems.
The second provided training in how to build positive behavioral
regulation skills in children. The parent training workshops were
conducted by the investigators or graduate students in clinical psy-
chology who were trained and supervised by the investigators.
Workshops were held in evenings or weekends on 2 consecutive
weeks and lasted for 2 hours each. Parents were given an informa-
tional manual elaborating workshop content to take home to useas a
Math Intervention Overview. After caregivers completed the
workshops, participants were randomly assigned to either the math
intervention group or a standard psychoeducational treatment con-
trast group. The standard psychoeducational treatment consisted of
a comprehensive neurodevelopmental evaluation and assistance with
educational placement and development of the individualized edu-
cational plan within the context of their home school. In addition to
the standard psychoeducational services, those in the math interven-
tion group received 6 weeks of tutoring services. The curriculum used
for individuals functioning from a kindergarten to a third-grade level
was adapted from the High Scope Curriculum Series (Hohmann,
1991) but was modified for individualized instruction. The preschool
curriculum was developed separately by a staff special educator who
had served as a consultant on curriculum development for the Head
Start programs in both a national and local capacity. The preschool
curriculum was then adapted to fit an instructional format parallel to
that of the High Scope Curriculum. Caregivers in the math interven-
tion group also received instruction in supporting math learning at
home and weekly home assignments to complement the individual-
ized tutoring sessions. The staff special educator also met with the
child’s teacher to discuss the alcohol-related neurodevelopmental
problems the participant had and the individualized educational
goals for the program.
Math Interactive Learning Experience (MILE). The math-related
intervention component of this socio-cognitive habilitation program
was called MILE to describe the interactive learning experiences
needed to habilitate the underlying neurodevelopmental deficits that
contribute to math difficulties in this group. The MILE program
rests on thetheory that thereare basic cognitive functions supporting
mathematical cognitions, which impact academic achievement and
adaptive functioning skills. We opted not to use strategies or
programs that either ‘‘taught to the test’’ or emphasized rote mem-
orization of math facts. We reasoned that the latter, verbally based
memory strategies, might impact test scores in the short term but
would be vulnerable to the memory-retrieval problems often reported
in this population (Mattson et al., 1998; Schonfeld et al., 2001) and
would not provide the foundation for later learning. In addition,
such strategies would have minimal impact on their behavioral and
adaptive life skills that are also impacted by mathematical cognit-
ions. The program also incorporated an active learning approach to
instruction, which was adapted from the ‘‘plan-do-review’’ method-
ology developed by the High-Scope Perry Preschool Project and was
found to have positive long-term consequences on academic achieve-
ment and educational attainment (Luster and McAdoo, 1996;
Weikart and Schweinhart, 1992) among high-risk children and to be
beneficial in cognitive rehabilitation programs for children with
acquired brain damage (Ylvisaker, 1998).
There were several key components of the instructional program
designed to compensate for the neurodevelopmental difficulties
commonly seen in alcohol-affected children. A slower pace of
instruction using interactive experiences was used so that informa-
tion of size, quantity, time, sequences of events, and mathematical
operations could be fully processed and integrated. This pace was
important to compensate for slower speed of processing (Burden
et al., 2005; Jacobson et al., 1992, 1993, 1994; Kable and Coles,
2004b) and disruptions to myelin development (Lancaster, 1994; Ma
et al., 2005; Riikonen et al., 1999; Riley et al., 1995; Wozniak et al.,
2006), which have been linked to prenatal alcohol exposure. We also
included tangible objects and used tools (such as vertical number
lines to facilitate learning that adding results in numbers going up
and subtracting results in numbers going down) to compensate for
deficits in visual/spatial processing (Aronson and Hagberg, 1998;
Carmichael-Olson et al., 1998; Coles et al., 2002; Kaemingk and
Paquette, 1999; Spohr et al., 1993; Ueckerer and Nadel, 1996) and
poor working memory (Kodituwakku et al., 1995; Rasmussen, 2005).
Traditional methods of math instruction where two-dimensional
worksheets and visual imagery are used to perform the designated
operations put children with such deficits at a disadvantage and have
been linked to one of the subtypes of developmental dyscalculia
(Geary, 1994, 1993). Repetitive experiences were provided in which
participants were required to label, a left hemisphere function, their
visual-spatial perceptions, a right hemisphere function, to compen-
sate for poor interhemispheric transfer of information. The latter has
been linked to prenatal alcohol exposure and may result from
disruption to structural (Mattson and Riley, 1996; Mattson et al.,
1996, 1992; Riley et al., 1995; Roebuck et al., 2002; Swayze et al.,
1997) and microstructural characteristics of the corpus callosum
(Ma et al., 2005; Wozniak et al., 2006). Online feedback regarding
patterns of errors and mediation of the experience to improve
integration were also provided. Finally, poor graphomotor skills
commonly associated with prenatal alcohol exposure (Coles et al.,
1991; Conry, 1990; Mattson et al., 1993) may also impact math
learning and computation in that the initial learning of the
orthographic characteristics of the symbols (like numbers and math-
ematical signs) may be negatively impacted and later computations
requiring neatness and column alignment may be impaired. We used
materials from an existing program ‘‘Handwriting without Tears’’
(Olsen, 2001) and adapted writing materials to facilitate understand-
ing of starting points and column alignment to compensate for these
KABLE ET AL.
Children and caregivers were evaluated before participating in the
group workshops and within 4 weeks of completing the tutoring
program. To control for time between assessments, a participant in
the standard psychoeducational group was assessed in the same week
as a participant in the math intervention group. Children were eval-
uated by a psychologist or psychology trainee who was blind to
group status. Caregivers completed questionnaires and a structured
interview with a staff member while their child was being assessed.
Satisfaction. Following the workshops, caregiver satisfaction was
assessed using Likert scale responses to questions regarding their
experiences with the specific treatment components and interactions
with staff members. The scale ranged from 0 to 4 with 4 indicating
strongly agree and 0 indicating strongly disagree.
Treatment and FAS Knowledge. Caregiver knowledge regarding
the neurodevelopmental compromises associated with prenatal
exposure to alcohol, the specific challenges to learning presented by
these difficulties, and behavioral regulation principles were assessed
by questionnaires using multiple-choice formats. Analagous forms
were given before the workshops and at posttesting, with order of
items and their respective choices randomized for each of the 3
assessment points to minimize practice effects.
Behavioral Outcomes. To measure caregivers experience of chil-
dren’s behavior, the Child Behavior Checklist (Achenbach and
Rescorla, 2001a, 2001b) was administered at pretest and posttest.
The test includes 100 problem behaviors that are rated as ‘‘not true,’’
‘‘sometimes true,’’ or ‘‘very true’’ by the reporter. Derived scores are
a T score with a mean of 50 and a standard deviation (SD) of 10
points, with higher scores reflecting more behavioral disturbance.
Items are clustered into subscales, which are then aggregated into
summaryscores. An overall Total Problems score as well as summary
scores for Internalizing and Externalizing Problem Behaviors are
Academic Outcomes. Math achievement was assessed at pretest
and at posttest, using several measures. All children were adminis-
tered the Test of Early Mathematical Ability, 2nd edition (TEMA-2;
Ginsburg and Baroody, 1990), a standardized test for assessing early
mathematical development, and selected math-related subtests from
the Bracken Early Concept Scales Revised (Bracken, 1998). For chil-
dren 5 and over, the Key Math-R/NU (Connolly, 2001) was also
administered, which is a standardized test measuring several distinct
areas of mathematical concepts for school-age children. Parallel
forms of the Key Math-R/NU were used to minimize practice effect.
For children under 5 years, developmental testing of premath
concepts such as more/less, same/different, intuitive numbering, con-
servation, and sequential organization of objects along intensity and
magnitude was conducted. This measure was adapted from math
concepts administered as part of the Bayley Scales of Infant Devel-
opment, second edition (Bayley, 1993). Finally, the quality of
number writing was assessed in all the children using an instrument
developed as part of this study (The Number Writing Task, Coles
et al., 2004). The instrument consists of 7 items that assess order,
orientation, neatness, consistency, and general recognizability of the
Eighty-seven participants were consented and enrolled
in the study but only 61 completed study requirements for
randomization. Of these, 56 completed posttesting 1. The
math group had 2 dropouts. The first child was removed
from the home by child-protective services and the care-
giver of the second withdrew, stating that the travel to the
center and another child’s care prevented the family from
continuing with treatment. Within the no-math group, 3
failed to return to posttesting. This resulted in 93.5% of
the math group and 90.0% of the psychoeducational con-
trast group being evaluated at posttesting. The average
duration between pretest and posttesting was 149.45
(SD542.3) days for the math intervention group and
149.4 (SD532.8) days for the psychoeducational contrast
group. There were no group differences in retention or
time between testing. Power analysis of the proposed
design and number of participants suggested that effects
at or above the Z250.17 will be detected with an 80%
Table 1 provides the sample characteristics. Com-
parisons of demographic, birth, and neurocognitive
characteristics of the participants yielded only 1 group dif-
ference. The participants in the math intervention group
had significantly lower birth weights than did those in the
Readiness to Learn Outcomes
Attendance at workshops ranged from 2 to 14 partici-
pants, with the average being 6.1. Client satisfaction
ratings of the workshops were very high, with over 90%
of participants agreeing that the trainers were knowledge-
able and the materials were easy to understand and helpful
to them (see Table 2). Significant gains in knowledge were
foundfor both the FAS/caregiver advocacy
49)54.0, po0.05] and behavioral regulation [F(1,50)5
15.9, po0.000) information presented at the workshops.
Caregiver ratings of their children’s behavior before the
workshops and at posttesting were contrasted. Parents
reported significantly fewer problem behaviors at posttest-
ing on the Internalizing Problem Behavior [F(1,50)58.1,
po0.006], Externalizing Problem Behavior [F(1,50)5
21.9, po0.000], and Total Problem Behavior [F(1,
50)515.4, po0.000] summary scores of this instrument.
The mean group differences are given in Table 3.
Math Treatment Effect
Because of the disparity in ages and in methods for
assessing math functioning, overall math development was
determined by combining the raw scores of the Test of
Early Mathematics, selected math subtests from the
Bracken Basic Concept Scale Revised, and the Number
Writing Task using a principal components analysis with a
varimax rotation. A math development factor was gener-
ated for pretest that accounted for 92.7% of variance
between math measures and for the posttest, 90.2% of
variance. A multivariate analysis of covariance was then
performed on postmath functioning scores. After control-
ling for premath functioning [F(3,43)55.34, po0.003], a
significant math treatment effect was found on postmath
functioning. Both groups demonstrated gains in math
knowledge, but significantly higher gains [F(3,43)52.97,
THE MILE PROGRAM FOR ALCOHOL-AFFECTED CHILDREN
po0.04, partial Z250.17, medium effect size) were found
in the group receiving the math component of the pro-
In addition, performances from pretest to posttest were
coded (yes/no) to reflect whether a clinically significant
gain was obtained on any of the math measures adminis-
tered. A clinically significant gain was defined as a gain of
greater than one SD from pretest to posttest performance
on any of the 4 math outcome measures used in the study.
In addition to the mean outcomes, the math treatment
group was also significantly more likely to demonstrate a
clinical gain [58.6 vs 23.1%, w (1,55)57.1, po0.008] from
pretest to posttest (see Table 4).
These results suggest that a targeted psychoeducational
program that addresses the alcohol-related neurodevelop-
mental difficulties that contribute to poor math learning
and performance may help to remediate deficits associated
with prenatal alcohol exposure. Although the program
was relatively short in duration, participants in the math
treatment group were more likely to make a clinically
significant gain than were participants assigned to the
standard psychoeducational intervention condition. These
findings, as well as other recent intervention outcome stud-
ies (Adnams et al., 2006; Coles et al., in press), should help
Table1. Characteristics of the Sample
Math Psychoeducational contrastp-value
Child age at enrollment
% African American
% Adopted nonrelative
% With 2 caregivers
Number of adults in home
Number of children in home
Rank of gross household income (535,000–49,999)
Birth length (cm)
Birth head circumference (cm)
DASbgeneral cognitive ability
Beery–BuktenicacVisual Motor Integration
aThepedscoreisthe sumofthe30weighteditemsonastandardpediatricdysmorphia checklistFernhoff etal. (1980)usedtoidentifyalcohol-related
dysmorphic features. This checklist is a modification of the usual ‘‘genetics’’ checklist where characteristics associated with the disorder are listed and
weighted based on their saliency for the diagnosis (e.g., hypoplastic philtrum is a ‘‘3’’). Scores 4 10 are assumed to indicate alcohol-related dysmor-
bDAS refers to the Differential Ability Scales (Elliot, 1983). Performance is measured using a standard score that has a mean of 100 and a SD of 15
cBeery–Buktenica Developmental Test of Visual Motor Integration (Beery and Buktenica, 1997). Performance is measured using standard scores
that have a mean of 100 and a SD of 15 points.
dNepsy (Korkman et al., 1997). Performance is measured using a scaled score that has a mean of 10 and a SD of 3 points.
SD, standard deviation.
Table2. Reported Satisfaction With Workshop Training
Parent training workshop
Caregiver advocacy (n582) Behavioral regulation (n579)
Therapist friendly and helpful
Therapist encouraged questions
Therapist easy to follow
Materials easy to understand
Information presented at good pace
aUsing a Likert scale ranging from 0 to 4 with 4 indicating strongly agree and 0 indicating strongly disagree.
bPercent in agreement indicates the percentage who stated they agreed or strongly agreed with the statement.
KABLE ET AL.
dispel the beliefs that alcohol-affected individuals are
resistant to habilitative services and should generate inter-
est in further defining methods of delivery of services
to optimize their impact on the functioning of alcohol-
affected children. Although the long-term impact of this
relatively short-term psychoeducational intervention was
not assessed, the results provide evidence that effective
teaching methods can improvelearningfor alcohol-affected
Although these results are promising, there remain a
number of unanswered questions. The program used
involves several components, including case management,
parent training, teacher consultation, and individual
instruction with the child. These components were devel-
oped by the authors from theory and clinical experience
with alcohol-affected children, but the results of this study
do not clarify which, if any, are necessary or sufficient for
effecting the changes observed. Additional research is
needed to assess the relative contributions of the various
elements of the program to establish their respective con-
tributions to the treatment effect. To better understand the
specificity of the intervention to alcohol-related neurode-
program to children with similar neurodevelopmental def-
icits (e.g., William’s syndrome) and to children with other
learning difficulties should be explored. Although the pro-
gram used specific strategies and supportive educational
tools designed to compensate for known alcohol-related
neurodevelopmental deficits, this evaluation does not
establish that these were necessary nor does it establish
that the model used to understand alcohol-related math
deficits was valid. Additional comparisons of other one-
on-one instructional programs are needed to establish that
these were integral to the treatment effect. It is possible
that one-on-one instruction alone may have been all that
was needed to effect change regardless of the strategies and
tools utilized in the learning process.
Translation of this program into the community envi-
ronments may also be problematic in that it may be
challenging to apply one-on-one instructional sessions in
a standard school environment. Most academic instruc-
generalizability of this
tion is carried out in a group format and interventions,
such as this one, are costly in person power and physical
space for school systems to implement. In addition, our
intervention lasted only 6 weeks and further research is
needed to clarify the duration of treatment that would be
the most optimal for children and most efficient in terms of
long-term retention of skills. The MILE approach focused
both on the child and the caregiver and it would be helpful
to examine whether simply educating caregivers to incor-
porate math-enrichment activities into the children’s
everyday lives would be sufficient to enhance their mathe-
matical concept development.
Another possible problem with the implementation
of this program may arise because caregivers of alcohol-
mathematical thinking as their first priority for habilitative
services. However, a greater understanding of the effect of
mathematical cognitions on everyday behavior and
adjustment may make this intervention more desirable.
Many believe that math concepts are limited to what is
learned in a traditional math curriculum; however, over
the course of development, math constructs, such as
classifying, sorting, patterning, adding, and subtracting,
become incorporated into our everyday problem-solving
skills, allowing us to predict the outcomes of our behavior
as well as the environmental events that influence our well-
being. For example, learning time concepts like ‘‘a
minute’’ and ‘‘an hour’’ and the repetitive pattern of days
used in a calendar allow for a sense of predictability in
sustained focus and work-related tasks. A poor under-
standing of relationships between time, events, and
objects, including understanding sequencing of events
needed for appropriate causal attributions, and accepting
time delays in access to preferred items or activities can
contribute to frustration and lead to the kind of behavior
problems and ‘‘meltdowns’’ that are commonly reported
among our alcohol-affected clients (Blackston et al., 2005).
As such, we believe that psychoeducational interventions
that target math cognitions will not only enhance an
academic skill, which can lead to better school and job
outcomes, but better problem-solving skills that can be
applied to everyday life.
The workshops offered to caregivers of alcohol-affected
children in this study were intended to improve under-
Table3. Outcomes: Comparison of Caregivers’ Responses at Pretest and
Knowledge of FAS and advocacya
Knowledge of behavioral regulationa
aAverage number of correct choices on knowledge questionnaires
using multiple-choice formats.
bAverage T scores from the Achenbach Child Behavior Checklist
(CBCL; Achenbach and Rescorla, 2001a, 2001b).
FAS, fetal alcohol syndrome.
Table4. Percentages of Participants With a Clinically Significant Gainaby
contrast (n526) (%)
aA clinically significant gain was defined as a gain of 41 standard
deviation from pretest to posttest performance on any of the 4 math out-
come measures used in the study.
THE MILE PROGRAM FOR ALCOHOL-AFFECTED CHILDREN
standing of the disorders and learning problems associated
with prenatal alcohol exposure and to provide tools to
support positive intervention and behavioral manage-
ment. We hoped to provide this information in a brief but
effective model that would be acceptable to caregivers in
both content and format and we hoped to see positive
behavioral changes in children. The study results suggest
that parents and caregivers of children with FAS(D) ben-
efited from instruction focusing on understanding the
neurodevelopment impact of prenatal alcohol exposure.
In addition, they found information about methods for
‘‘navigating’’ the educational and social services systems
helpful. These services were well received and were associ-
ated with reports of improved behavior at posttesting.
Although it is possible that these findings may be tempo-
rary or may be the results of experimenter or participant
expectation, they do suggestthat educationalinterventions
may be helpful for caregivers and may lead to positive
behavioral change for children.
Additional research is needed to further assess the clin-
ical efficacy of the parent training components of this
intervention. This study used only a pre–post test design
and not a control group with random assignment to eval-
uate the impact of the workshop as was done to evaluate
the math intervention component. This design limits the
conclusions that can be drawn from this component of the
study but suggests that further evaluations are needed. In
addition, the study would have been improved by collect-
ing behavioral ratings from other parties (i.e., teachers) in
the child’s environment as they could provide an objective
assessment of the children’s behavioral functioning and
would not necessarily be as invested in the treatment as
caregivers. Although this was originally planned in our
protocol, we experienced difficulties with getting teachers
to return questionnaires in a timely manner and opted to
not collect them at the posttesting assessment and waited
until a later follow-up assessment to collect this informa-
Although there is much left to do, the results of this
study represent a hopeful beginning in designing and eval-
uating interventions for alcohol-affected individuals and
their families. To date, most of the animal research and the
limited human studies (Coles et al., in press; Guerri et al.,
2005; Padgett et al., 2006; Stromland et al., 2005) have
been promising and have suggested that interventions have
the potential to improve the quality of life for alcohol-
affected individuals. Supporting families and affected
individuals require continued investigation into evidence-
based methods for improving their lives.
The authors would like to thank the children and fam-
ilies who participated in this research. Their efforts inspire
us. In addition, we would like to thank Pat NeSmith, who
helped us develop our preschool curriculum for the project
and the following staff members who helped us along the
way: Dwain Blackston, Betsy Meeks, Donna Dent, Ryan
Beck, Cindy Barnes-Schoell, Christiana DeGregorie,
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