1. Perseveration – The lens by which those afflicted with FASD interpret their relationships and environment.
XXXIVth International Congress on Law and Mental Health. Vienna
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2. Barry Stanley
This presentation is about FASD and the effects of PAE from the perspective of the history and ongoing abuse of alcohol, the ongoing and rapid development of our understanding of brain function, and the explosive, exponential growth of epigenetics.
Do not be put off by the complexity of each of these. We do not have to be experts on these subjects, we do have to have an understanding of their significance for FASD. We especially need to have this understanding because those who are experts in neurology and epigenetics do not pay any consideration to PAE and FASD.
Disorders of neurogenesis of cortical and subcortical structures in rat brain limbic system during fetal alcohol syndrome formation. Morfologiia. 2012;141(2):18-22.
Abstract
“Disorders of neurogenesis of cortical and subcortical structures in rat brain limbic system were studied in the offspring of rats that received ethanol during pregnancy. The methods used included the staining of histological sections with cresyl violet, in vitro culture, and electron paramagnetic resonance. Prenatal alcohol intoxication was shown to induce the disturbances in proliferative activity of granular layer cells in the hippocampal dentate gyrus, neuron- and glioblast migration,
enhancement of free NO and lipoperoxide production and cell death. This resulted in the changes in the number of neurons in cortical and subcortical structures of rat brain limbic system and in fetal alcohol syndrome formation.”
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3. “Perseverance, dear my lord, keeps honour bright….”
William Shakespeare ~ Troilus andCressida. Act 3, scene
Barry Stanley
There is little research on Perseverance. There is research on the components of brain function that contribute to Perseverance.
The word has been used in English for centuries. ” Perseverance, dear my lord, Keeps honour bright; to have done, is to hang Quite out of fashion, like a rusty nail In monumental mockery. William Shakespeare ~ Troilus andCressida. Act 3, scene Quotations by Shakespeare. Quotes.dictionary.com [April, 2014]
References
Reasoning, Learning, and Creativity: Frontal Lobe Function and Human Decision-Making Anne Collins, Etienne Koechlin. Published: March 27, 2012 DOI: /journal.pbio
Hippocampal involvement in contextualmodulation of fear extinction. Jinzhao Ji, Stephen Maren. Hippocampus, 17: 749–758. doi: /hipo.20331
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4. Perseverance -a complex process essential for executive and adaptive functioning.
Barry Stanley
Perseverance is a normal, positive process of persistence in overcoming adversity, or a difficult problem. The degree to which it is pursued in any give situation varies according to an individual’s degree of interest and psychological profile. Yet within this normal range we all have the ability to consider other issues and shift our focus accordingly, when required. This critical part of brain function enables us to relate and adapt to our immediate and future environment and relationships.
It is an amazing and beautiful example of the complex function of the human brain so necessary for appropriate executive and adaptive functioning.
Referencew
The Stream of Consciousness. William James (1892).First published in Psychology, Chapter XI. (Cleveland & New York, World).
Grit: Perseverance and Passion for Long-Term Goals. Angela L. Duckworth, Christopher Peterson, Michael D. Matthews and Dennis R. Kelly. Journal of Personality and Social Psychology, 2007, Vol. 92, No. 6, 1087–1101
The Stream of Consciousness William James (1892).
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5. 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
Barry Stanley.
Research into brain functions that contribute to Perseverance has concentrated mostly on the Prefrontal Cortex. However, it does not act in isolation, but works with other brain areas to promote Perseverance.
Reconciling the Roles of Orbitofrontal Cortex in Reversal Learning and the Encoding of Outcome Expectancies. GEOFFREY SCHOENBAUM, MICHAEL P. SADDORIS, THOMAS A. STALNAKER. Annals of the New York Academy of Sciences, 1121: 320–335.
PERSONALITY PROCESSES AND INDIVIDUAL DIFFERENCES. Grit: Perseverance and Passion for Long-Term Goals. Angela L. Duckworth, Christopher Peterson, Michael D. Matthews and Dennis R. Kelly. Journal of Personality and Social Psychology, 2007, Vol. 92, No. 6, 1087–1101
The Role of Orbitofrontal Cortex in Decision Making. LESLEY K. FELLOWS. Annals of the New York Academy of Sciences, 1121: 421–430.
Role of Orbitofrontal Cortex Connections in Emotion. NANCY L. REMPEL-CLOWER. Annals of the New York Academy of Sciences, 1121: 72–86.
Dopamine neuron systems in the brain: an update. Anders Björklund, Stephen B. Dunnett . Volume 30, Issue 5, p194–202, May Proceedings from the 2013 Annual Meeting of The Florida Society of Neurology.
The contribution of the medial prefrontal cortex, orbitofrontal cortex, and dorsomedial striatum to behavioral flexibility. Ragozzino ME. Ann N Y Acad Sci Dec;1121:
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6. 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
4- The ability to shift focus when necessary
“Our research has focused primarily on three EFs: updating
(constant monitoring and rapid addition/deletion of working
memory contents), shifting (switching flexibly between tasks
or mental sets), and inhibition (deliberate overriding of dominant
or prepotent responses).” Miyake and Friedman, 2012
Barry Stanley
There is little written on the over all on the actual brain function that occurs with the process of Perseverance.
Therefore we have to look at its components, that have been researched. 1-
The Orbitofrontal Cortex: Novelty, Deviation from Expectation, and Memory. MICHAEL PETRIDES. Annals of the New York Academy of Sciences, 1121: 33–53.
Interactions between the Orbitofrontal Cortex and the Hippocampal Memory System during the Storage of Long-Term Memory. SETH J. RAMUS, JENA B DAVIS, RACHEL J DONAHUE. CLAIRE B DISCENZA. ALISSA A. WAIT. Annals of the New York Academy of Sciences, 1121: 216–231.
Prediction, cognition and the brain. Andreja Bubic, D. Yves von Cramon, Ricarda I. Schubotz. Frontiers in Human Neuroscience. March 2010 | Volume 4 | Article 25 |
Prefrontal Cortex Lesions Modify the Spatial Properties of Hippocampal Place Cells. Rachel J. Kyd and David K. Bilkey. Cereb. Cortex (2003) 13 (5): doi: /cercor/
Amnesia and the hippocampus. Cipolotti L , Bird CM. Curr Opin Neurol Dec;19(6):593-8.
What does the hippocampus really do? Jarrard LE. Behav Brain Res Nov;71(1-2):1-10. 2-
Neural Encoding in the Orbitofrontal Cortex Related to Goal-Directed Behavior. TOMOYUKI FURUYASHIKI, MICHELA GALLAGHER. Annals of the New York Academy of Sciences, 1121: 193–215.
Damage of GABAergic neurons in the medial septum impairs spatial working memory and extinction of active avoidance: Effects on proactive interference. Kevin C.H. Pang et.al. Hippocampus, 21: 835–846. doi: /hipo.20799
Flexible Neural Representations of Value in the Primate Brain. C. DANIEL SALZMAN, JOSEPH J. PATON, [...], and SARA E. MORRISON. Ann N Y Acad Sci. Dec 2007; 1121: 336–354. Published online Sep 13, doi: /annals 3-
Neuronal Mechanisms in Prefrontal Cortex Underlying Adaptive Choice Behavior. JONATHAN D. WALLIS. Annals of the New York Academy of Sciences, 1121: 447–460.
Lights, Camembert, Action! The Role of Human Orbitofrontal Cortex in Encoding Stimuli, Rewards, and Choices. JOHN P. O'DOHERTY. Annals of the New York Academy of Sciences, 1121: 254–272.
Specialized Elements of Orbitofrontal Cortex in Primates. HELEN BARBAS. Ann. N.Y. Acad. Sci. 1121: 10–32 (2007).
Motivational Salience Signal in the Basal Forebrain Is Coupled with Faster and More Precise Decision Speed. Irene Avila, Shih-Chieh Lin. Plos Biology. Published: March 18, 2014 DOI: /journal.pbio
Network hubs in the human brain. Martijn P. van den Heuvel Olaf Sporns. Trends in cognitive sciences. Volume 17, Issue 12, p683–696, December DOI:
The Role of Medial Prefrontal Cortex in Memory and Decision Making. David R. Euston, Aaron J. Gruber, Bruce L. McNaughton. Neuron 76, December 20, 2012
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7. 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
Barry Stanley
This is no doubt a generalized simplification of the process. The areas of the brain associated with these processes are areas that are affected in FASD.
Prenatal alcohol exposure, PAE [and possibly preconceptual alcohol exposure, PCAE ] interferes with the development of all these components of the brain that enable this complex process of perseverance.
Cognitive neuroscience of emotional memory. Kevin S LaBar, Roberto Cabeza. Nature Reviews Neuroscience 7, [January 2006]
Specific and nonspecific thalamocortical functional connectivity in normal and vegetative states.Zhou J, Liu X, Song W, Yang Y, Zhao Z, Ling F, Hudetz AG, Li SJ. Conscious Cogn Jun;20(2):
Cingulate gyrus morphology in children and adolescents with fetal alcohol spectrum disorder. Olivia A Bjorkquist et.al. Psychiatry Res February 28; 181(2): 101.
Moment-to-moment tracking of state value in the amygdala Marina A. Belova, Joseph J. Paton, and C. Daniel Salzman. J Neurosci. Oct 1, 2008; 28(40): 10023–10030.
Re-valuing the amygdala. Sara E. Morrison and C. Daniel Salzman. Curr Opin Neurobiol. Apr 2010; 20(2): 221–230.
The hippocampal formation--orbitomedial prefrontal cortex circuit in the attentional control of active memory. Wall PM , Messier C. Behav Brain Res Dec 14;127(1-2):
Emotion, Cognition, and Mental State Representation in Amygdala and Prefrontal Cortex C. Daniel Salzman, Stefano Fusi. Annu Rev Neurosci. 2010; 33: 173–202. doi: /annurev.neuro
The human hippocampus and spatial and episodic memory. Burgess N , Maguire EA, O'Keefe J. Neuron Aug 15;35(4):
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8. Perseveration {Impaired Perseverance}
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
Barry Stanley
Like “perseverance” the word “perseveration” is the noun derived from the verb “persevere” . The first has positive connotations, the second negative connotations. Perseverance, the original noun still used today, goes back to Elizabethan times. It has maintained its positive connotations.
The word “perseveration” was introduced in the early 20th century in the context of psychology, psychiatry and brain function. Since then its usage has developed in the context of abnormalities of the normal process of perseverance.
Savanna Piet
“… when I am perseverating and Mark asks me a question such as if I want something to eat, I can’t think and become agitated and frustrated and I don’t know what to say. ”
“Perseveration…or the difficulty experienced in switching from one pattern of behaviour or method of working to another.”
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9. 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
References
Response perseveration in rats exposed to alcohol prenatally. Riley et.al. Pharmacology, Biochemistry, And Behavior [Pharmacol Biochem Behav] 1979 Feb; Vol. 10 (2), pp
Abel E, Sokol R. Incidence of fetal alcohol syndrome and economic impact of FAS-related anomalies. Drug Alcohol Depend 1987 Jan;19(1):51-70
Verbal learning and memory in children with fetal alcohol syndrome. Mattson SN, Riley EP, Delis DC, Stern C, Jones KL. Alcohol Clin Exp Res Aug;20(5):810-6
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10. 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.
Barry Stanley
This requires confirmation with neurological research; a difficult process. Meanwhile it is the logical conclusion when transition reactions are viewed through the FASD lens. In addition interventions based upon the brain based origins of FASD behaviour are more effective than the traditional interventions based upon traditional concepts of responsibility, blame and punishment.
References
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11. But society’s 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.
Barry Stanley. THE REAL IMPACT OF FASD. North Bay, Ontario. 9th September, 2004
FASD effects genetics, teratology, embryology; the anatomy and physiology of most parts of the body, including the fetus and placenta; cellular anatomy, physiology and pathology; neurology, neuroanatomy, neurophysiology and neuropathology; early childhood development; the education system and its deficiencies; the judicial system and its deficiencies; criminality and mental health.
Those who understand this, as opposed to only knowing of it, will be forced to examine the meaning of culpability and responsibility. [I would now add “ gene expression”]
Savanna Pietrantonio
“… perseveration leads to addictive coping strategies … such as video gaming, drugs, alcohol, eating, shopping,  anything in order to deal with the uncomfortable feeling. ”
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12. 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
Barry Stanley
The word “perseveration” was introduced in the early 20th century in the context of psychology, psychiatry and brain function. Since then its usage has developed in the context of abnormalities of the normal process of perseverance.
References
On the Perseverative Tendency. William S. Foster. The American Journal of Psychology, Vol. 25, No. 3 (Jul., 1914), pp
This manuscript anticipated the present concepts of perseveration. He covered the use of the word “perseveration” over the preceding fourteen years.
 The review deals with observations and theories of normal perseverance and not the neurodevelopmental disabilities as seen with FASD. However, it does acknowledge that the perseverative tendency includes a number of functions that arise from the brain, including what sounds like stuck-in-set Perseveration.
> “Not in the field of memory alone however, but also in such different fields as those of feeling, rhythm, association, action and thought, do we find the appeal to the freely rising or to the persisting mental formation, and at least one writer has based
 a theory of introspection upon the perseverative tendency….According to some writers not only do we have a perseveration of mental processes, but also of forms of  consciousness and of mental acts”.
Varieties of perseveration: a comparison of two taxonomies. Goldberg E. J Clin Exp Neuropsychol Dec;8(6):
Emotion-related learning in individuals prenatally exposed to alcohol: an investigation of the relation between set shifting, extinction of responses, and behavior. Kodituwakku PW , May PA, Clericuzio CL, Weers D. Neuropsychologia. 2001;39(7):
 A composite neural network model for perseveration and distractibility in the Wisconsin card sorting test. Kaplan GB , Sengör NS, Gürvit H, Genç I, Güzeliş C. Neural Netw May;19(4):
Role of activity-dependent BDNF expression in hippocampal–prefrontal cortical regulation of behavioral perseverance. Kazuko Sakataa, et.al. PNAS | September 10, 2013 | vol. 110 | no. 37 | 15103–
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13. 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 Nov: 37[11]:
Barry Stanley
As it always seems with FASD, more research is required re. Perseveration.
“ We propose a new taxonomy for perseveration consisting of three categories which are distinctive at the levels of clinical features, process, and neuroanatomy. 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.
Recurrent perseveration, the unintentional repetition of a previous response to a subsequent stimulus, involves an abnormal post-facilitation of memory traces and is related neuroanatomically to posterior left hemisphere damage.
Continuous perseveration in the inappropriate prolongation or repetition of a behavior without interruption. It involves a deficit in motor output and is most
common in patients with damage to the basal ganglia” Sandson J. Albert M.L. Perseveration in behavioral neurology. Neurology Nov: 37[11]:
WHAT IS PERSEVERATION?. Mark Ylvisaker, Ph.D..
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14. 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]
Barry Stanley
Since 1987 further research has shown that other areas of the brain, as well as the frontal lobe, contribute to executive functioning, perseverance and perseveration.
References
The Nature and Organization of Individual Differences in Executive Functions: Four General Conclusions. Akira Miyake and Naomi P. Friedman. Current Directions in Psychological Science 21(1) 8– 14
The Unity and Diversity of Executive Functions and Their Contributions to Complex ‘‘Frontal Lobe’’ Tasks: A Latent Variable Analysis. Akira Miyake et.al. Cognitive Psychology 41, 49–100 (2000)
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15. Areas of the brain associated with Stuck-in-Set 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 Parkinson’s
the tuberoinfundibular pathway transmits dopamine from the hypothalamus to the pituitary gland.
Minor pathways[3]
Ventral tegmental area [VTA] > amygdala VTA > hippocampus VTA > cingulate gyrus VTA > olfactory bulb [Wikipedia. 2014]
References
Perseveration As A Sign Of Diffuse And Focal Brain Damage: R S. Allison. The British Medical Journal. Vol. 2, No (Nov. 5, 1966), pp
WIKI.
mesolimbic pathway The mesolimbic pathway transmits dopamine from the ventral tegmental area (VTA) to the limbic system via the nucleus accumbens. The VTA is located in the midbrain, and the nucleus accumbens is in the ventral striatum. The "meso" prefix in the word "mesolimbic" refers to the midbrain, or "middle brain", since "meso" means "middle" in Greek. schizophrenia, ADHD
mesocortical pathway The mesocortical pathway transmits dopamine from the VTA to the frontal cortex. The "meso" prefix in "mesocortical" refers to the VTA, which is located in the midbrain, and "cortical" refers to the cortex. schizophrenia, ADHD
nigrostriatal pathway The nigrostriatal pathway transmits dopamine from the substantia nigra to the striatum. This pathway is associated with motor control. Parkinson's disease, chorea
tuberoinfundibular pathway The tuberoinfundibular pathway transmits dopamine from the hypothalamus to the pituitary gland. This pathway influences the secretion of certain hormones, including prolactin. "Infundibular" in the word "tuberoinfundibular" refers to the cup or infundibulum, out of which the pituitary gland develops. hyperprolactinaemia
Minor pathways[3]Ventral tegmental area (VTA) → AmygdalaVTA → HippocampusVTA → Cingulate gyrusVTA → Olfactory bulb
Perseveration in behavioral neurology. Sandson J , Albert ML. Neurology Nov;37(11):
Varieties of perseveration: a comparison of two taxonomies. Goldberg E. J Clin Exp Neuropsychol Dec;8(6):
MATURATIONAL INFLUENCES ON PERSEVERATION OF AVOIDANCE AND REVERSAL LEARNING AFTER SELECTED BRAIN DAMAGE IN RATS. James F. BRENNAN, Carolyn A. COHEN, and Peter A. BERTUCCI. ACTA NEUROBIOL. EXP. 1988, 48:
Bilateral lesions of the mesencephalic trigeminal sensory nucleus stimulate hippocampal neurogenesis but lead to severe deficits in spatial memory resetting. Ishii T, Suenaga R, Iwata W, Miyata R, Fujikawa R, Muroi Y. Brain Res Jun 25;1342:74-84.
Perseveration. Part 1: a review. Gillian Hotz and Nancy Helm-Estabrooks. Brain Injury, 1995, Vol. 9, No. 2,
The role of prefrontal cortex in perseveration: Developmental and computational explorations. Yuko Munakata, J. Bruce Morton, and Jennifer Merva Stedron. Connectionist Models of Development. Ragozzino ME. Ann N Y Acad Sci Dec;1121:355-75
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16. Being Bored
- a disturbing mental state of cognitive and emotional chaos
N. 19yrs - diagnosed at 5yrs
“When I’m bored I have lots of thoughts in my head. It is uncomfortable. I don’t 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”
Barry Stanley
Therapeutic Perseveration – there is little research on the abnormal neurological processes involved in being “bored” There is research into the resting, background activity of normal brain function. It would seem that in some way, related to perseveration, this background activity is interfered with- as described in the clinical examples.
Being bored-
Survival is not just physical it is also mental. After living with FASD for 34 years and seeing those with FASD in my offices daily for 10 years I made a huge leap forward in my understanding of FASD. It came once more from listening to words spoken and not interpreting them from my self – perspective. I could not count the number of times “being bored” was complained of by those with FASD. I assumed that the meaning of “bored” was the same for them as for me. For me it merely meant having nothing to do and quickly moving on. It was never an issue and not unpleasant.
N.. was 19 years old when she first came to see me. She had been diagnosed at the age of five and had been adopted and raised in an ideal rural setting with an understanding family, consequently she had not experienced the secondary disabilities
of FASD. The event that caused them to see me was an unexpected and out of character disappearance for a weekend. N. had been persuaded to visit a male, contacted on the internet. Fortunately she was quickly located and returned home by the police.
N. was still at high school. She had an I.E.P. but was many credits behind as she had significant disabilities, in great contrast to her mature, attractive appearance. Expectations were explored and adjusted. The daily manifestations of N’s disabilities
were reviewed in the context of “stealing’, “lying” and inappropriate communications over the internet.
The family understood that N would always require care and supervision. This was a concept that N. struggled with, a frequent scenario with FASD. It was on their twelfth visit.
I think it was her attitude, not stated – of course, what else would I do? What’s your problem.- that indicated an underlying assumption on her part that we understood the reason why she did this when bored.
N’s mother said “as usual, she spends all her time playing video games” Immediately N said, “ I do that when I’m bored”.
I realized, for the first time, that actually I did not understand why she played video games continuously when bored.
So I asked her “what is being bored like?” Her answer was a revelation.
She was never able to tell me what the thoughts were. She did make it clear that she had no control over them and the process was not nice. They were associated with uncontrolled changes in feeling good / bad.
‘When I’m bored I have lots of thoughts in my head. It is uncomfortable. I don’t like it. So I play video games and it all goes away”
So I started to ask. In doing so it was important not to ask leading questions, to be unambiguous and to listen.
Here are some examples of being “bored” . In some cases they were from people who I had been seeing for years, and I had had no idea of their true state of mind,
“ - hundreds of radios playing at the same time”
“ - a thousand televisions all playing at the same time”
“ – beehive full of bees buzzing around in my head”
Since they have always been told that they are bored when in fact they are in a state of mental chaos, inevitably they will come to believe the two are the same.
They describe different ways of controlling the mental chaos, but they all have one thing in common, it is a process of perseveration.
What those with FASD perseverate on for relief of their chaotic [bored] mind is extremely variable. It is determined by the environment that they grew up in, with its values and behaviors, and positive and negative experiences.
[We all have core values and behaviors that are laid down in the first few years of life. In the case of FASD those core values and behaviors are essentially set in stone. If they are negative those with FASD are more prone to secondary disabilities.]
Understandably, the cognitive, information and memory deficits of the individual also determine what they do for relief. In some cases they may read, play sports or music; all seen as very positive, if not obsessive.
For those with more serious neurological disabilities simple forms of relief are used; many parents are familiar with the intense texting and video game playing of their children, and how aggressive or violent they may be when this activity is taken from
them.
We need to ask ourselves how we would react if we suffered from violent migraines and had our pain medications taken from us with no other means of relief, we might then have some understanding of the role perseveration plays in the relief of such chaotic
states.
Ashley Smith Born-- New Brunswick, 29th. January, Died-- alone, in isolation-- Grand Valley Institution for Women, Kitchener, Ontario, Canada. 19th. October, 2007.
“My life I no longer love
Get it over with while the time is right
I’d rather be set free above
Late some rainy night
Turn black as the night and cold as the sea Say goodbye to Ashley
Miss me but don’t be sad
No more caged up Ashley
I’m free, where I want to be
Wishing I were free
Free like a bird “
The Ashley Smith Report, New Brunswick Ombudsman and Child and Youth Advocate, June 2008.
References
Complex relationships between structural and functional brain connectivity. Lucina Q. Uddin. Trends in Cognitive Sciences December 2013, Vol. 17, No. 12
Neurocognitive biases and the patterns of spontaneous correlations in the human cortex. Tal Harmelech and Rafael Malach. Trends in Cognitive Sciences, December 2013, Vol. 17, No. 12
Cortical dynamics revisited. Wolf Singer. Trends in Cognitive Sciences, December 2013, Vol. 17, No. 12
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17. 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.”
Barry Stanley
I have many times asked “ If you were placed in a dark room, no windows, no sound, no one to talk to, nothing to listen to or play with, nothing to do- what would happen?”
The answers are always similar. “ I would go mad or I would kill myself.
Yet solitary confinement is still practiced in our prison systems, and we know many inmates have FASD.
Savanna Pietrantonio
"this feels VERY uncomfortable when someone or the environment tries to distract me from my perseveration.  For example, I have surgery on Tuesday and that is taking up all the space in my mind.  I was invited to go to a friend's place for dinner tonight, and to meet with another friend on Monday however to think about going is overwhelming.  I do not want to go; I just want to stay isolated in my thoughts.  It feels disruptive or distracting from my perseveration thoughts on the surgery.   The painful part is the perseveration is causing suffering and obsessions and unhealthy habits like not going to yoga when that is the one thing that will help my mind.  I don't even want to practice my DBT skills because it feels dangerous and uncomfortable for my mind to think of anything else.  It feels scary.  I am aware of this difficulty but I will have to endure it until the surgery is done.”
“ ....it is hard to feel empathy and compassion or understanding of others.  That is a skill I have to teach my brain as it seems it is not a built in mechanism of FASD people.  So yes, you have to use effort to use your imagination as it does not come naturally to be in another's shoes.  This is why I could be a funeral director so well because I felt nothing but people with FASD learn how to "fake it" to appear normal or empathetic.”   ”
… The "letting go part" left on it’s own my brain will process the event in it’s own time and in it’s own way.  The perseveration seems to be how it processes it.  I have noticed that it takes a longer and larger amount of time than it would a normal person and that talking about it over and over and over helps the processing.  It feels like it needs to come out.  If this is allowed and accepted and validated the process is quicker, healthier and less painful.  There are times when I am very able to use my skills to move on.  This had to be taught to me as it is not a natural function.  I had to be taught the skills to use to let go, surrender and accept.  To be comfortable with the discomfort.  A trained mind is way more comfortable than an untrained mind.  This is where DBT skills, yoga, aerobic exercise, meditation, gratitude, affirmations help me to let go and take me through the process and I am stronger on the other side of it.  These things saved my life.  In the past I would self harm.    
“ … this helped me … saying these things helped me process it … and feeling like I helped someone …” 
“Savanna:  slide 26 on being bored.  I wish there was another word to communicate to others this state as bored is not strong enough a word.  I like your explanation of mental state and cognitive and emotional chaos.  That is more accurate.  As it is a state of restless irritable discontent that also manifests physically (heart rate goes up, cannot be still, I usually pace, I can’t focus. I feel impending doom. ** noted that your notes in the slide reinforced that being bored was very different for an FASD person ”
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18. Consequences of isolation and sensory deprivation for those with FASD
Temporary compliance
Self harm, suicide, “madness”
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19. FORCED TEMPORARY “POSITIVE” PERSEVERATION
Does not work: only “positive” to the therapist/custodian
The story of E. The story of A. The story of Z. The story of C. . For positive change positive perseveration is necessary.
Barry StanleyNow that we understand the significance and importance of environmental input in the process of normal perseverance, adaptive and executive functioning we can see that isolation and sensory deprivation are a gross challenge to our sanity.
 E.. was a teenager referred by a psychiatrist. This was unusual since FASD is rarely considered in Psychiatry.
She was a resident of a youth detentions centre and had been referred for the possible diagnosis of FASD.
Both her parents had been alcohol abusers. She had a long history of violence. Finally she had been detained for treatment of her violent behavior.
She had the history of secondary disabilities, interrupted schooling, drug and alcohol abuse and incarceration.
She had shackles on which her worker would not remove. At first E. refused to speak to me so I asked the worker about E..s’ background.
E.. had been incarcerated because of her repeated violence to others, usually when under the influence of alcohol.
“She is a model client” said the worker. “She has had only one violent episode. That was when she first came. She is cooperative and is attending school. We are so proud of her”.
Eventually E.. became engaged in our conversation.
I asked about the violent incident.
“She pissed me off so I smashed her in the face”.
“So what happened then?” I asked.
“They left me in a black room. There were no lights or windows, no one to talk to. There was nothing to do. I hated it.”
“Have you thought about hitting any one since then? I asked.
“Lots of times” she answered.
“Oh please, don’t listen to her. She is not like that” the worker said, obviously upset.
“If you have thought about hitting people lots of times why haven’t you done so? I asked.
“If I did that they would put me back in the black room. I don’t want that” she replied.
The next question was “how much do you think that if you hit someone you will be put back in the black room?.
“ All the time” was her answer
I do not know what happened to E.. after this visit. She never returned.
My report stated that she likely had FASD but this would have to be confirmed with psychological testing according to our Canadian Guidelines for the diagnosis of FASD.
I would like to believe that after her discharge she would have returned home reformed and able to follow a happier and fulfilling life. I think it more likely however that once she returned home her perseveration on the black room would cease and the next time she appeared in front of a judge on charges of assault he would say ” young lady you have shown that when you want to you can improve your behaviour. Obviously you have not learned your lesson yet” Then he would incarcerate her for a longer period and the cycle would be repeated.
I can understand that some would criticize me for including the story of E. since no actual diagnosis of FASD was made, as far as I know. However her history was supportive of the diagnosis and more importantly I was to find many other examples of temporary positive perseveration once I started to look.
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20. 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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21. “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.
Barry Stanley
It is my observation that those with FASD exist in two states, 1 -a mind of chaotic, uncontrolled and uncomfortable thoughts, usually described as being bored.
2- a mind perseverating [ super focused ], with or without physical activity.
They seek the second to escape the first.
What they perseverate on is determined by their particular set of cognitive, emotional, information processing, memory, expressive and sensory disabilities; as well as their early childhood experience and their immediate environment, including how others relate to them.
What they may perseverate on to soothe themselves extends from cutting, provoking others, to more acceptable behaviors, such as playing video games, reading and sports.
Alcohol and hard drugs are used to obliterate the 1st state of mind. Those with FASD can often stop using them providing they have an alternative focus of perseveration. This is not true of Marijuana and Tobacco, which generally appear to have a specific action that reduces their multiple chaotic thoughts and allows them to focus on one process. The “medicinal” use of pot is lost if it is used to excess, in which case it assumes the harmful role of other street drugs. .
References
The Unengaged Mind: Defining Boredom in Terms of Attention John D. Eastwood, Alexandra Frischen, Mark J. Fenske, and Daniel Smilek. Perspectives on Psychological Science 7(5) 482–495
Causes of boredom: The person, the situation, or both? Kimberley B. Mercer-Lynn, Rachel J. Bar, John D. Eastwood. Personality and Individual Differences 56 (2014) 122–126
IS TRAIT BOREDOM REDUNDANT? Kimberley B. Mercer-Lynn, Jennifer A. Hunter, and John D. Eastwood. Journal of Social and Clinical Psychology, Vol. 32, No. 8, 2013, pp
Hitting the Wall: Youth Perspectives on Boredom, Trouble, and Drug Use Dynamics in Rural New Mexico Cathleen E. Willging, Senior Scientist, Gilbert A. Quintero, Associate Professor, and Elizabeth A. Lilliott. Youth Soc. Jan 1, 2014; 46(1): 3–29.
Published online Sep 21, doi: / X
Characteristics and motivations of absconders from forensic mental health services: a case-control study. Stephanie R Penney, Stephanie Fernane, Alexander I Simpson. BMC Psychiatry 2014, 14:91 doi: / X-14-91
Neural networks underlying affective states in a multimodal virtual environment: contributions to boredom. Krystyna A. Mathiak, Martin Klasen, [...], and Klaus Mathiak Front Hum Neurosci. 2013; 7: 820. Published online Nov 28, doi: /fnhum
I can’t get no satisfaction: Potential causes of boredom. Gerritsen, Cory J. Toplak, Maggie E. Sciaraffa, Jessica and Eastwood, John D. Department of Psychology, York University, 4700 Keele St. Toronto, ON M3J 1P3
“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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22. EXECUTIVE FUNCTIONS
> Updating – constant monitoring and rapid addition/ deletion of working memory contents.
> Shifting – switching flexibly between tasks or mental sets.
> Inhibition – deliberate overriding of dominant or prepotent responses.
{Miyake and Friedman}
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23. 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 behavior, 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
Barry Stanley –. Research into the effects of prenatal alcohol exposure lags behind the rapidly expanding research in Neuroscience. Nevertheless, the areas of the brain involved in executive functioning are affected by prenatal alcohol exposure.
References
Neurocognitive Profile In Children With Fetal Alcohol Spectrum Disorders Piyadasa W. Kodituwakku. Dev Disabil Res Rev ; 15(3): 218–224. doi: /ddrr.73.
Hippocampal-neocortical functional reorganization underlies children’s cognitive development. Shaozheng Qin et.al. nature NEUROSCIENCE published online 17 August 2014; doi: /nn.3788
Differential Sensitivity of Prefrontal Cortex and Hippocampus to Alcohol-Induced Toxicity. Anna-Kate Fowler et.al. PLoS One. 2014; 9(9): e
Prenatal ethanol exposure differentially affects hippocampal neurogenesis in the adolescent and aged brain. Gil-Mohapel J et.al. Neuroscience Jul 25;273:
The Nature and Organization of Individual Differences in Executive Functions: Four General Conclusions. Akira Miyake and Naomi P. Friedman. Current Directions in Psychological Science 21(1) 8– 14
The impact of early and late damage to the human amygdala on `theory of mind' reasoning. P. Shaw et.al. Brain (2004), 127, 1535±1548
Executive functions and their disorders. Rebecca Elliott. British Medical Bulletin 2003; 65: 49–59
Executive function of the hippocampus in social behavior in the rat. Maaswinkel H, Gispen WH, Spruijt BM. Behav Neurosci Aug;111(4):
Executive function mediates effects of white matter hyperintensities on episodic memory. Neuropsychologia. Aug 2011; 49(10): 2817–2824. Colleen M. Parks et.al.
Thalamic neuromodulation and its implications for executive networks. Carmen Varela. Front Neural Circuits. 2014; 8: 69.
Brain metabolic alterations in adolescents and young adults with fetal alcohol spectrum disorders. Fagerlund A et.al. Alcohol Clin Exp Res Dec;30(12):
Fetal alcohol exposure and temporal vulnerability: effects of binge-like alcohol exposure on the ventrolateral nucleus of the thalamus. Livy DJ , Maier And SE, West JR. Alcohol Clin Exp Res May;25(5):
Brain diffusion abnormalities in children with fetal alcohol spectrum disorderLebel C et.al. Alcohol Clin Exp Res Oct;32(10):
Extensive deep gray matter volume reductions in children and adolescents with fetal alcohol spectrum disorders. Nardelli A , Lebel C, Rasmussen C, Andrew G, Beaulieu C. Alcohol Clin Exp Res Aug;35(8):
In vitro Neurogenesis from Neural Progenitor Cells Isolated from the Hippocampus Region of the Brain of Adult Rats Exposed to Ethanol during Early Development through Their Alcohol-Drinking Mothers Ashok K. Singh et.al.
Alcohol & Alcoholism Vol. 44, No. 2, pp. 185–198, 2009
MECHANISMS OF FETAL ALCOHOL SPECTRUM DISORDERS. SHANNON ELIZABETH WILSON. A Dissertation Submitted to the Office of Graduate. August 2010.
Task-set switching deficits in early-stage Huntington's disease: implications for basal ganglia function. Aron AR1, Watkins L, Sahakian BJ, Monsell S, Barker RA, Robbins TW. J Cogn Neurosci Jul 1;15(5):
A decrease in the size of the basal ganglia following prenatal alcohol exposure: a preliminary report.Mattson SN1, Riley EP, Jernigan TL, Garcia A, Kaneko WM, Ehlers CL, Jones KL. Neurotoxicol Teratol May-Jun;16(3):283-9
Moderate-level prenatal alcohol exposure alters striatal dopamine system function in rhesus monkeys. Schneider ML et.al. Alcohol Clin Exp Res Sep;29(9):
REGIONAL BRAIN VOLUME REDUCTIONS RELATE TO FACIAL DYSMORPHOLOGY AND NEUROCOGNITIVE FUNCTION IN FETAL ALCOHOL SPECTRUM DISORDERS. Florence F. Roussotte, Kathleen K. Sulik, [...], and Elizabeth R. Sowell.
Hum Brain Mapp April ; 33(4):
Structural and functional brain integrity of fetal alcohol syndrome in nonretarded cases.Clark CM1, Li D, Conry J, Conry R, Loock C. Pediatrics May;105(5):
Brain imaging and fetal alcohol spectrum disorders Christie L. McGee(a) and Edward P. Riley. ANN IST SUPER SANITÀ 2006 | VOL. 42, NO. 1: 46-52
Ethanol attenuates spatial memory deficits and increases mGlu1a receptor expression in the hippocampus of rats exposed to prenatal stress. Van Waes V. Alcoholism: Clinical and Experimental Research Vol 33, No 8, 2009, pp .
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24. Conclusion – Questions
Generalized Executive dysfunction and Stuck-in-Set Perseveration apply to Culpability and Criminal Responsibility
Questions
Is Stuck-In-Set Perseveration common to all those diagnosed FASD?
Which comes first Executive Functioning or Perseverance ? - Are they
both aspects of one simultaneous complex neurological process?
Is it possible to have impaired Executive Functioning without Stuck-in
Set Perseveration { impaired Set Shifting and Perseverance } ?
References
Developmental pathways to functional brain networks: emerging principles. Vinod Menon. Trends in Cognitive Sciences, December 2013, Vol. 17, No. 12
Risk and Protective Factors for Criminality among Adults with FASD. Elisa Radford-Paz. Thesis. The School of Graduate Studies, Laurentian University, Sudbury, Ontario. Canada. Copyright Elisa Radford-Paz, 2013
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25. For all those who live with the disabilities of FASD
And in memory of Ashley Smith; born, New Brunswick, 29th. January, 1998; died,
alone, by her own hand, in isolation at the Grand Valley Institution for Women,
Kitchener, Ontario, Canada. 19th. October, 2007.
“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.
“My life I no longer love I’d rather be set free above
Get it over with while the time is right Late some rainy night
Turn black as the night and cold as the sea Say goodbye to Ashley
Miss me but don’t be sad I’m free, where I want to be
No more caged up Ashley Wishing I were free
Free like a bird”
-From the Ashley Smith Report, New Brunswick Ombudsman and Child and Youth
Advocate, June 2008.
Barry Stanley. Vienna. July, 2015.
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