fasd and perseveration.

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Perseveration The lens by which those
afflicted with FASD interpret their relationships
and environment.Accommodating Fetal Alcohol
Spectrum Disorders Hearts and Minds in the
Downtown Eastside

Vancouver, B.C. 15th October, 2014

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Perseverance Perseveranc
e, dear my lord, keeps honour bright. William
Shakespeare Troilus andCressida. Act 3, scene
31. 150-3


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Perseverance -a complex process essential for
executive and adaptive functioning.
The
Stream of Consciousness William James (1892).

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4

• Perseverance
• Perseverance is a process of taking hold,
  and letting go to move on.
• Historically we have only looked at the
  taking hold part.
• We need to look at the letting go part in
  order to understand Perseveration, which prevents
  moving on.
• Conscious is always interested more in one part
  of its object than in another and welcomes and
  REJECTS, or chooses all the while it thinks.
  William James

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Perseverance requires 1-
Emotional and cognitive recall of the past
experience 2- Analysis and assessment of what
is recalled, in the context of the present and
anticipation of the future 3- Awareness and
assessment of inner self and present environment,
in relation to 1 and 2


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Perseverance areas of the brain involved

• 1- Emotional and cognitive recall of the past -
• amygdala, hippocampus, HPA axis, medial
  temporal lobe, prefrontal cortex
• 2- Analysis and assessment of what is recalled,
  in the context of the present and anticipation of
  the future -
• unimodal sensory-cortices, lateral and
  medial parietal and temporal areas
  orbitofrontal,medial frontal and dorsolateral
  prefrontal cortex, premotorcortex, insula,
  cerebellum, basal ganglia, amygdala and thalamus
• 3- Awareness and assessment of inner self and
  present environment, in relation to 1 and 2
• Insular and anterior cingulate cortex,
  fronto-parietal networks, hippocampus
  connections, thalamus connections, amygdala.
• The development of all these areas of the
  brain is disrupted by PAE

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BILL


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Lessons I Learned From Bill

• Listen to the words spoken
• Deal with the world that is Bills, not mine
• Redirect, distract. Do not confront,
• Wait for Bill to stop perseverating on the issue,
• if possible.

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Perseveration
When the normal process of perseverance is
interfered with in FASD, and an appropriate shift
of focus is not possible, the process becomes one
of Perseveration executive and adaptive
functioning are compromised. She had lived as
indifferent to safety and security as anyone well
can, and that must have meant that she relied on
the present moment---- that she leaned in against
its grain---- in a way the rest of us do not
know.----------------- She embraced the random,
the contingent, the chaotic. Nuala O Faolain.
The Story of Chicago May Epilogue page 302 .
Riverhead Books. New York. 2005.


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History of Perseveration and FASD

• References to perseveration and FAS go back to
  the 1980s, mostly in the context of behaviour
  i.e. transition reactions in the home and school
  settings.
• The early explanations were- selfish, stubborn,
  often diagnosed as Oppositional Defiant Disorder

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Transition Reactions are due to Interruption of
Perseveration

• Interruption of Perseveration, by the will of
  others or circumstances beyond their control, is
  an extremely uncomfortable process for those with
  FASD- so they react.

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But societys view of those with FASD is distorted

• The behavior, especially Perseveration, of
  those affected is seen as an affront to society
  that is willful in nature, and not the
  manifestation of disorganized neurological
  development that it truly is.
• In order to understand we needs to look
  through the FASD lens.

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The Hot Dog Story a daily occurrence for those
with FASD

• The mistaken interpretation of those who do
  not understand fasd
• They dont learn from experience not completely
  true. They may have a degree of knowledge but
  cannot apply it in the moment.
• They are selfish- not true. They are not able to
  consider the needs of others because they are
  stuck in the moment.
• Other wrong explanations of perseverative
  behavior. They are-
• stupid, attention seeking, not caring, not
  interested, lazy

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Perseveration, FASD, ADHD and the significance of
psycho-stimulants

• ADHD is the most common other diagnosis.
• Psycho-stimulants increase focus
  Perseveration.
• There is an association between
  psychostimulents and cardiac deaths, and a
  possible association with suicide.
• PAE is the most common cause of cardiac
  abnormalities, if we include ventricular/atrial
  septal defects.
• There is increased risk of suicide with FASD
• Conclusion - those diagnosed FASD should
• -have a cardiac assessment before being
  prescribed Ritalin etc.
• -be followed closely for suicidal and
  homicidal thoughts when prescribed Ritalin etc.
  The individuals affect may not reflect their
  perseveration on suicide

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• History of
  Perseveration
• According to some writers not only do we
  have a perseveration of mental processes, but
  also of forms of consciousness and of mental
  acts.
• On the Perseverative Tendency. William S.
  Foster. 1914
• It is proposed that clinical features of
  prefrontal syndromes need not imply the presence
  of selective structural or biochemical damage to
  prefrontal cortex, and that a structurally
  diffuse CNS disease often masquerades as a
  selective frontal-lobe disease.
• Varieties of perseveration a comparison of two
  taxonomies. Goldberg E. 1986

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The Three Forms of Perseveration

• Stuck-In-Set. Always seen with
  FASD?
• Recurrent. May be seen with
  FASD
• Continuous. May be seen with FASD
  
• Sandson J. Albert M.L. Perseveration in
  behavioral neurology. Neurology. 1987 Nov
  3711 1736-41

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Stuck-In-Set Perseveration

• Stuck-in-set perseveration, the inappropriate
  maintenance of a current category or framework,
  involves an underlying process deficit in
  executive functioning and is related
  neuroanatomically to frontal lobe damage.
  Sandson J. Albert M.L. 1987
• Question
• Which comes first Executive Functioning or
  Perseveration?
• or - are they both aspects of the same
  complex neurological process?

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Areas of the brain associated with Perseveration
and known to be affected by Prenatal Alcohol
Exposure
HIPPOCAMPUS PREFRONTAL CORTEX BASAL
GANGLIA DOPAMINE SYSTEM -
. mesolimbic pathway Schizophrenia,
ADHD mesocortical pathway Schizophrenia, ADHD
nigrostriatal pathaway Parkinsons the
tuberoinfundibular pathway transmits dopamine
from the hypothalamus to the pituitary
gland. Minor pathways3 Ventral tegmental area
VTA gt amygdala VTA gt hippocampus VTA gt
cingulate gyrus VTA gt olfactory bulb



Wikipedia. 2014


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Positive Perseveration in FASDwhat you hear
when you listen

• 1- From the streets
• 2- For the sake of the children
• 3- Without support - relapse

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Positive Perseveration in FASD

• All different, but the same.
• There are always exceptions to the rule- so be
  careful with expectations and conclusions.
• No matter what the individuals profile is- they
  will always require support in some way.
• The early childhood environment influences how
  the neurodevelopmental disabilities of the
  individual will contribute to the individuals
  belief systems and progress throughout the
  lifespan.

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FORCED TEMORARY POSITIVE
PERSEVERATION Does not work only positive to
the therapist/custodian

• The story of E.
• The story of A.
• The story of C.
• The story of Z.
• For positive change positive perseveration is
  necessary.

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Forced temporary positive perseveration

• Is never lasting
• Is dangerous
• Is misleading for the professional and the law
• All therapies should be followed up long term
  and the results included in the record.
• More cooperation required between agencies,
  doctors, therapists and the law - with
  appropriate safeguards for the individual.

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Belief Systems

• Those with FASD do have belief systems.
• Explore them indirectly by observing and
  listening.
• Endorse them if positive and helpful.
• If negative, do not challenge or confront.
  Depending on the level of disability encourage
  different focus.

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Diagnosis brings relief, in most cases.

• The diagnosis of FASD brings relief that
  often multiple diagnoses from the DSM have failed
  to do.
• - especially when illustrated with true
  stories of others with FASD.
• The teenager who wants to be like the rest is
  more likely to resist the diagnosis.
• The adult who has suffered so much is more
  likely to welcome the diagnosis.

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Being Bored
- a disturbing mental state of cognitive and
emotional chaos

• N. 19yrs - diagnosed at 5yrs
• When Im bored I have lots of thoughts in my
  head. It is uncomfortable. I
• dont like it. So I play video games and it all
  goes away
• M. 27yrs diagnosed at 23yrs
• .. like a beehive full of bees buzzing around
  in my head
• She Ashley Smith had indicated to the staff
  that she was bored
• and was looking for attention and she wanted
  staff to enter into her cell
• so that she could fight with them--
• Ms. Grafton, Security Intelligence Officer, Grand
  Valley Institution for Women, Kitchener, Ontario,
  Canada
• Her father, .. said his daughter was picking
  paint off the cell walls out of boredom.
• 14yrs. Tasered and straight jacketed while in a
  holding cell devoid of stimulation.
• http//www.cbc.ca/canada/story/2009/02/03/stungun
  -advocate.html

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Savanna Pietrantonio"FASD Survival Strategy
Teacher"

• bored a lot, more thoughts, not nice, better
  with alcohol
• bored is worse than being angry
• After understanding perseveration and having
  dialectical behavioural therapy and mindfulness
  therapy-
• perseveration can at times be a gift from the
  universe to FASD people.
• perseveration can also be our worst enemy.  The
  key is to understand our brain and how we can use
  it to our best advantage. 

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Therapeutic Perseveration

• what those with FASD do when bored is often seen
  as a process of pleasure, and not a process of
  relief that it truly is.
• the distorted lens of society views these
  processes of relief as positive and rewards them,
  or negative and punishes.
• - both are based upon incorrect premises.

However, boredom can also be a chronic and
pervasive stressor with significant psychosocial
consequences. Indeed, boredom is even associated
with mortality, lending grim weight to the
popular phrase - bored to death - The Unengaged
Mind Defining Boredom in Terms of Attention,
John D. Eastwood Perspectives on Psychological
Science 7(5) 482 495


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CORRELATION gt CAUSE AND EFFECT Correlation
- a mutual relationship or connection between
two or more things Because there is a
correlation it can not be assumed that there is
a cause and effect. But, there cannot be cause
and effect without correlation. Where there is
a strong, significant correlation relating to the
health of individuals and society the medical
profession has a moral and ethical duty to
investigate possible cause and effect.


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FOLIC ACID
AND SPINA BIFIDA 1970s- 1980s Correlation
Spina Bifida was related to
Folic Acid deficiency in the mothers. 1991
Cause and Effect confirmed - Publication of the
results from the Medical Research Council Vitamin
Study U.K. 1992, 14 months later the Centers
of Disease Control and Prevention U.S.A.
recommended Folic Acid to reduce incidence of
Spina Bifida


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MENTAL ILLNESS AND PAE/FASD 1996
Report University of Washington, Seattle ,
U.S.A.
Streissuguth et.al 1996

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• Neurotransmitters, Neuromodulator Systems and
  Hormones affected by Prenatal Alcohol Exposure.
• - Dysregulation of Insulin Growth Factors
• - NMDA glutamate receptors gt synaptic plasticity
  and memory systems
• GABA a,b,c gamma-aminobutyric acid gt C.N.S.
  inhibitory and excitatory during development
  neurotransmitter gt cell membrane function
• - Reduced Choline Acetyltransferase gt decreased
  acetylcholine gt Hippocampus gt memory
  Neuromodulator gt platicity, arousal, reward,
  sensory perceptions and
• sustained attention.
• Hydroxylase gt mood, appetite, sleep, memory,
  learning
• - Decreased Dopamine receptor function gt reward
  learning, reward seeking. Decreased levels of
  Dopamine in the Prefrontal Cortex, Ventral
  Tegmental Area
• - Hypothalamic-Pituitary Axis gt differing
  activation gt stress responsiveness. Male/Female
  differential stress responsiveness gt protective
  role of estrogens.
• Inhibition of Serotonin synthesis and expression
  of serotonin precursor, tryptophan
• The correlation between prenatal alcohol exposure
  and the abnormalities of the development and
  function of neurotransmitter systems goes back to
  the 1980s

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• CORRELATIONS THAT SHOULD BE EXPLORED
• Normal brain anatomy and function with the brain
  anatomy and function of FASD e.g. as in
  Perseveration.
• Diagnoses from the DSM and FASD including the
  brain anatomy and function of DSM mental
  illnesses with those of FASD.
• The role of Epigenetics in brain development
  with the role of Epigenetics on the brain
  development of FASD and Mental Illnesses.

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Executive Functions are Kieran
OMalley

• A Group of Cognitive Abilities
• Self-Regulation of Behaviors
• Sequencing of Behaviors
• Cognitive Flexibility
• Response Inhibition
• Planning
• Organization of Behavior
• A Future-Oriented Process
• Goal Directed
• Delayed Gratification
• An Integrative Process
• Perception
• Attention
• Memory
• Motor
• General Intelligence

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Areas of the brain associated with Executive
Functioning

• Prefrontal Cortex - with
  connections to
• Thalamus, Basal Ganglia, Hippocampus,
  Amygdala
• These areas are all affected in FASD, by
  prenatal alcohol exposure.
• Which comes first Executive Functioning or
  Perseveration?
• or - are they both aspects of the same
  complex neurological process?
• Instead, the emerging view suggests that
  executive function is mediated by dynamic and
  flexible networks Rebecca Elliott. 2003
• Our findings support the idea that
  stress-related events occurring before birth have
  long-lasting effects on brain function and
  behaviour, and suggest that the impact of ethanol
  on cognition is not only dose and
  duration-dependent, but also critically
  influenced by early life experiences. Van Waes
  V. 2009
• These findings are unique in that they
  demonstrate for the first time that deficits in
  neurogenesis associated with prenatal ethanol
  consumption appear later in life.
• Gil-Mohapel J et.al.2014

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Questions

• Is Stuck-In-Set Perseveration common to all
  those diagnosed FASD?
• Why are the correlations between the
  neuroscience of Perseveration and FASD/Prenatal
  Alcohol Exposure not being explored?
• Which comes first Executive Functioning or
  Perseverance ? - Are they both aspects of one
  simultaneous complex neurological process?
• What is the relationship of Perseveration
  caused by Prenatal Alcohol Exposure to the
  Perseveration of Mental Illnesses?
• What is the significance of the
  Perseveration of FASD to Criminal Activity how
  does it apply to Culpability and Criminal
  Responsibility?

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Parallel Tracks

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The Brain of Mental Illness
The Brain of FASD
Psychiatry and PAE/FASD are on parallel tracks.
The Psychiatry train is a closed train. Those on
the PAE/FASD train are reaching out but are not
seen or heard.

37
Parallel Tracks

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The Brain of Neuroscience
The Brain of FASD
Neuroscience and PAE/FASD are on parallel tracks.
The Neuroscience train is a closed train. Those
on the PAE/FASD train are reaching out but are
not seen or heard.

38
Parallel Tracks

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The Brain of Epigenetics
The Brain of FASD
Epigenetics and PAE/FASD are on parallel tracks.
The Epigenetic train is a closed train. Those on
the PAE/FASD train are reaching out but are not
seen or heard.

39

What to do? No amount of education or training
of those with FASD will be successful if the
caregiver, worker, mentor does not understand
the disabilities of FASD, and how they apply to
the individual.



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What to do?
What works for one may not work for another. The
individuals neuropsychological profile always
needs to be considered. Also, knowledge of the
individuals sensory profile is crucial.

• 
  Jodee Kulp www.Betterendings.org

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