Risk of Child Maltreatment

Children with a FASD appear to experience a greater incidence of child abuse and neglect (Kully-Martens, Denys, Treit, Tamana, & Rasmussen, Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012; Smith, Johnson, Pears, Fisher, & DeGarmo, Reference Smith, Johnson, Pears, Fisher and DeGarmo2007; Streissguth, Barr, Hogan, & Bookstein, Reference Streissguth, Barr, Kogan and Bookstein1996). Conry, Fast and Loock (Reference Conry, Fast and Loock1997) found that 73.1 per cent of youth with a FASD had experienced emotional, physical and/or sexual abuse. Similarly, Greenbaum and colleagues (Reference Greenbaum, Stevens, Nash, Koren and Rovet2009) found that 73 per cent of children with a FASD had experienced neglect or abuse in some form compared to 3 per cent of comparison groups of ‘typically developing children’ and ‘children with attention deficit hyperactivity disorder (ADHD)’.

Out-of-Home Care

Prenatal alcohol exposure is a highly significant issue for children in contact with child welfare/protective services. Children with a FASD can often be placed in out-of-home care due to ongoing issues of alcohol consumption within their families of origin. In South Australia, parental substance misuse is a contributing factor in approximately 70 per cent of cases of children entering out-of-home care, with alcohol being the most commonly used substance (Jeffreys, Hirte, Rogers, & Wilson, Reference Jeffreys, Hirte, Rogers and Wilson2009). The trauma of being removed from their family to be placed into out-of-home care and the addition of potential instability from multiple foster-care placement breakdowns can further compound the negative influence of the deficits exhibited by children with a FASD.

Caregiver Burden

Children with a FASD who are in out-of-home care can suffer multiple placement breakdowns as a result of their complex support needs and challenging behaviour (Paley & Auerbach, Reference Paley and Auerbach2010). Insufficient information about the extent of disability in children with a FASD and parenting stress have both been found to increase the chance of foster care placement breakdown (Brown, Bednar, & Sigvaldason, Reference Brown, Bednar and Sigvaldason2007). They are also more likely to be exposed to complex family backgrounds and stressful interpersonal relationships prior to entering foster care that can combine to make it difficult for foster carers to support them (Wilkins, Jones, Watkins, Mutch, & Bower, Reference Wilkins, Jones, Watkins, Mutch and Bower2013). This could be particularly detrimental to children with a FASD as placement stability and a stable, nurturing environment are strong predictors of improved behaviour and cognitive functioning (Green, Reference Green2007; Kalberg & Buckley, Reference Kalberg and Buckley2007), as well as more positive long-term outcomes (Streissguth, Bookstein, Barr, Sampson, O'Malley, & Young, Reference Streissguth, Barr, Bookstein, Sampson, O'Malley and Young2004). However, such stability may not be experienced by many.

Social Competence

Notwithstanding the range of factors affecting children entering care, the impaired social development of children with a FASD can have a significant negative impact on their lives. The nature and extent of social difficulties experienced by children with prenatal alcohol exposure is concerning. Children with a FASD experience extensive difficulty with many aspects of social relationships, including:

• • Poor social skills/social competence.

• • Difficulty forming interpersonal relationships.

• • Social relationship problems.

• • Display socially inappropriate behaviours.

• • Poor social judgement.

• • Difficulty perceiving and responding to social cues.

• • Externalising behaviour problems.

• • Difficulty exhibiting consideration for others.

  (Greenbaum et al., Reference Greenbaum, Stevens, Nash, Koren and Rovet2009; Kodituwakka, Segall, & Beatty, Reference Kodituwakku, Segall and Beatty2011; Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012; Mattson & Riley, Reference Mattson and Riley2000; Rasmussen et al., Reference Rasmussen, Becker, McLennan, Urichuk and Andrew2010; Streissguth, Aase, Clarren, Randels, LaDue, & Smith, Reference Streissguth, Aase, Clarren, Randels, LaDue and Smith1991)

Caregivers (including biological, foster, adoptive, and other) indicate children with a FASD have greater deficits in social responsibility and social skills, higher levels of hyperactivity (e.g. impulsivity, restless) and more internalising problems (e.g. anxiety, poor self-esteem) than children without prenatal alcohol exposure (Rasmussen et al., Reference Rasmussen, Becker, McLennan, Urichuk and Andrew2010). In the same study, respite workers also classified children with a FASD as hyperactive. These issues can be difficult for caregivers to manage.

Amongst the deficits documented in children with prenatal alcohol exposure are profound problems in processing social cues and managing their social relationships (Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012; Rasmussen et al., Reference Rasmussen, Becker, McLennan, Urichuk and Andrew2010; Streissguth et al., Reference Streissguth, Aase, Clarren, Randels, LaDue and Smith1991). Numerous studies have found that children with a FASD present with deficits in social cognition and social information processing (Dodge et al., Reference Dodge, Lansford, Burks, Bates, Pettit, Fontaine and Price2003; Greenbaum et al., Reference Greenbaum, Stevens, Nash, Koren and Rovet2009; Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012; McGee, Bjorkquist, Price, Mattson, & Riley, Reference McGee, Bjorkquist, Price, Mattson and Riley2009). Deficits in social information processing contribute to the interpersonal, behavioural and emotional issues often exhibited by children with a FASD (Dodge et al., Reference Dodge, Lansford, Burks, Bates, Pettit, Fontaine and Price2003; Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012).

Compared with typically developing children or to children with ADHD, children with a FASD have been found to have weaker social cognition and facial emotion processing ability (Greenbaum et al., Reference Greenbaum, Stevens, Nash, Koren and Rovet2009). Difficulties with social cognition appear to be predictive of children's behaviour problems. Kodituwakka, Segall and Beatty (Reference Kodituwakku, Segall and Beatty2011) concluded that the behavioural and adaptive problems of children with a FASD are not only related to their poor intellectual functioning, but also to poor executive functioning (e.g. planning, attention, verbal reasoning) and slowed overall processing of information, including social information. Social problem solving is also affected by social information processing (McGee et al., Reference McGee, Bjorkquist, Price, Mattson and Riley2009). Problem solving deficits can leave children with a FASD vulnerable to forming friendships with delinquent peers, victimisation, exploitation, peer pressure and, as a result, interaction with the criminal justice system (Fast & Conry, Reference Fast and Conry2009; Paley & Auerbach, Reference Paley and Auerbach2010).

These deficits in social competence have been found to become more severe with age (Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012; Thomas, Kelly, Mattson, & Riley, Reference Thomas, Kelly, Mattson and Riley1998; Whaley, O'Connor, & Gunderson, Reference Whaley, O'Connor and Gunderson2001). They may also be profound. Streissguth and colleagues (Reference Streissguth, Aase, Clarren, Randels, LaDue and Smith1991) found that the social functioning of some adults with a FASD was equivalent to the developmental level of a typically developing six-year-old.

Cognitive processes appear to be closely associated with the deficient social skills and socially inappropriate behaviours of these children (Greenbaum et al., Reference Greenbaum, Stevens, Nash, Koren and Rovet2009; Kodituwakku et al., Reference Kodituwakku, Segall and Beatty2011; Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012). A recent review of the neuropsychological profiles of children with prenatal alcohol exposure outlined a spectrum of issues that could contribute to their social difficulties, including problems with verbal and non-verbal learning, spatial processing, attention and motor difficulties (Kodituwakku et al., Reference Kodituwakku, Segall and Beatty2011).

In addition, the social difficulties experienced by children with a FASD are underpinned by cognitive impairments that are qualitatively different to those exhibited by children with ADHD or other difficulties (Mattson et al., Reference Mattson, Crocker and Nguyen2011). For example, children with a FASD have more difficulty in encoding (forming memories), rather than retrieving verbally mediated learning (Crocker Vaurio, Riley, & Mattson, Reference Crocker, Vaurio, Riley and Mattson2011). They have more difficulty with flexible problem solving, and in shifting attention from task to task (Coles et al., Reference Coles, Platzman, Raskind-Hood, Brown, Falek and Smith1997), rather than in focusing and sustaining attention. There appear to be specific deficits in the processing of facial emotions (Greenbaum et al., Reference Greenbaum, Stevens, Nash, Koren and Rovet2009). They also demonstrate impairment in adaptive, communicative and daily living skills that children with ADHD do not demonstrate (Crocker et al., Reference Crocker, Vaurio, Riley and Mattson2011). Greenbaum and colleagues (Reference Greenbaum, Stevens, Nash, Koren and Rovet2009) conclude the unique difficulties with social cognition and in the processing of emotional cues shown by children with a FASD may be central to their social difficulties. Research into the relationship between cognitive difficulties and social difficulties is ongoing (see Kodituwakku & Kodituwakku, Reference Kodituwakku and Kodituwakku2011).

Early Detection and Intervention

A critical question or concern for professionals and carers who support children with a FASD is whether or not these social difficulties can be ameliorated through specialised intervention. The neural plasticity of a child's developing brain (Johnston, Ishida, Ishida, Matushita, Nishimura, & Tsuji, Reference Johnston, Ishida, Ishida, Matushita, Nishimura and Tsuji2009; Paley & Auerbach, Reference Paley and Auerbach2010) may provide opportunity for children to learn the appropriate skills and behaviours to mitigate the above-mentioned deficits. Thus, early detection and intervention could provide the opportunity to improve these social skills deficits (Kodituwakku et al., Reference Kodituwakku, Segall and Beatty2011; Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012). However, very little research has been conducted on the effectiveness of such interventions amongst this population.

Only one social skills intervention, conducted with 100 children with prenatal alcohol exposure between the ages of six and 12 years, was found (Keil, Paley, Frankel, & O'Connor, Reference Keil, Paley, Frankel and O'Connor2010; Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012; O'Connor et al., Reference O'Connor, Frankel, Paley, Schonfeld, Carpenter, Laugeson and Marquardt2006). This intervention was based on the parent-assisted Children's Friendship Training procedure (Frankel, Reference Frankel, Hibbs and Jensen2005; Frankel & Myatt, Reference Frankel and Myatt2003) and used instruction, modelling, rehearsal, performance feedback, homework assignments and parent-led coaching during social play to improve social competence (O'Connor et al., Reference O'Connor, Frankel, Paley, Schonfeld, Carpenter, Laugeson and Marquardt2006). Separate concurrent sessions about the key social skills the children were being taught were also conducted with parents. When compared to the delayed treatment control group, children who received the training had significantly improved knowledge of appropriate social skills, improved social skills (parent-report), and decreased problem behaviours (parent-report). A three-month follow-up found that these results had been maintained. No treatment effects were found in teacher-reported social skills and problem behaviours; however, a shift towards improvement could be seen at the three-month follow-up.

The effectiveness of social skills interventions with both typically developing children (Hennessey, Reference Hennessey2007) and children with Asperger's syndrome (Beaumont & Sofronoff, Reference Beaumont and Sofronoff2008) suggest that such interventions could be effective in improving social skills deficits in children with a FASD. Some think that long-term, comprehensive social skills interventions may be effective in improving the social skills and behaviours of children with a FASD (Kully-Martens et al., Reference Kully-Martens, Denys, Treit, Tamana and Rasmussen2012). Further research on the effectiveness of specific interventions in improving the social skills of children with a FASD conducted within schools or other community programmes is needed.