Teachers' needs for an FASD-informed resource: A qualitative interview needs assessment based on the ADAPT-ITT framework
Abstract
Fetal alcohol spectrum disorders (FASD) represent a wide range of neurodevelopmental differences associated with prenatal alcohol exposure and are highly prevalent. The current study represents the initial stages in adapting the Families Moving Forward (FMF) Program, an evidence-based behavioral consultation intervention for caregivers of children with FASD, to a website for teachers. Aims were to understand teachers' needs and preferences for an FASD-informed intervention website and to assess the goodness of fit of the FMF Program to teachers and the school setting. Twenty-three teachers with experience teaching students with FASD were interviewed. Interviews were conducted via Zoom and lasted about 53 min on average. Data were transcribed verbatim and analyzed using qualitative content analysis in Dedoose. Three overarching themes represented teachers' needs for an FASD-informed resource: teachers need evidence-based FASD information and strategies, teachers have very little extra time, and the needs of special and general education teachers vary. Teachers were positive about the concepts of the FMF Program and felt they would have good fit. Teachers need an evidence-based FASD-informed intervention that is easy to use, concise, and responsive to varying needs and levels of experience. Results will inform the adaptation process of the FMF Program.
1 INTRODUCTION
Fetal alcohol spectrum disorders (FASD) encompass a range of developmental disabilities associated with prenatal alcohol exposure (PAE). An estimated 1.1%–5% of US children have an FASD (May et al., 2018), which can affect many aspects of neurodevelopment, including executive functioning, behavior and self-regulation, memory, attention, and learning (Mattson et al., 2019). These challenges can interfere with students' abilities to experience success in the classroom, despite many having relative strengths in cognitive ability, academics, and positively contributing to the classroom environment (Duquette et al., 2006; Flannigan et al., 2021; Kautz-Turnbull et al., 2022). However, teachers receive limited training in FASD and have minimal access to supports for students with FASD. This can prevent teachers from using effective behavioral strategies and appropriate accommodations; a recent scoping review found limited resources were available for teachers, and even fewer had been formally evaluated for efficacy and effectiveness (Dybdahl & Ryan, 2009; Koren et al., 2013; Lees et al., 2022). Additionally, parents report often having to educate their children's teachers on FASD. These difficulties are exacerbated by pervasive systems barriers parents face in advocating for services and supports in the classroom setting (Petrenko et al., 2020). Subsequently, these barriers contribute to high rates of school disruption (i.e., suspension, expulsion, and dropout), estimated at 60% (Streissguth et al., 2004).
Olson et al. (2023) have proposed 12 essential elements of FASD-informed care to address these barriers. These include acting early, reducing risks and promoting protections, reframing and accommodating, and offering developmentally appropriate treatment, among others. The authors emphasize that shifting toward FASD-informed care does not necessarily require a large-scale change in current practices but rather an improvement of existing systems and interventions to better serve the needs of people with FASD.
One such environment which has the potential to serve many people with FASD is the education system and school environment. The school environment provides children, especially young children, opportunities for social and cognitive development; without appropriate support, children with FASD miss out on these opportunities, placing them farther behind their peers. Thus, FASD-informed care in schools is essential to address disparities in care and allow these students to reach their full potential.
Existing FASD-informed interventions for teachers are limited. The majority are in-person trainings or workshops which demand time and resources, both of which are limited for most teachers. Another notable barrier is the location of in-person trainings, as teachers who do not live in major metropolitan areas must travel long distances to attend. Though some trainings are available online, these can be expensive, time-intensive, and can involve live webinars which span multiple days. Some resource websites exist, but none to our knowledge have been systematically developed and tested as an FASD-informed intervention for teachers. An intervention delivered via a self-paced website which can be accessed at will has potential to reach teachers in all areas and fit with their needs more efficiently than an in-person or virtual workshop.
Adaptation of evidence-based interventions (EBIs) has increased in recent years and provides an alternative to the time- and cost-intensive development of novel interventions. The ADAPT-ITT framework (Wingood & DiClemente, 2008) is an eight-step process by which an EBI is adapted to a new format or target population. Originally developed for HIV interventions, ADAPT-ITT has been used in child and family interventions (Calheiros et al., 2018; Storer et al., 2012; Studts et al., 2020). It includes eight steps: Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, and Testing (see Table 1).
| ADAPT-ITT stage | Tasks involved |
|---|---|
| Assessment | Needs assessment is conducted with the new target population using interviews or focus groups |
| Decision | Evaluation of goodness of fit of the EBI and the new target population |
| Adaptation | Original EBI is “theater tested,” or presented to a small sample of the new target population, who then provide feedback |
| Production | Creation of adaptation plan emphasizing the core elements of the intervention, including underlying theory and logic model, and results of the needs assessment and theater test; initial draft of adapted intervention created |
| Topical experts | Draft of adapted intervention is presented to experts in the field for feedback |
| Integration | Feedback from the topical experts is incorporated into the adapted intervention, leading to the second draft of the adapted intervention |
| Training | Study personnel and those delivering the intervention are trained |
| Testing | Adapted intervention is tested in the new target population in a small pilot/feasibility study and a subsequent larger randomized trial |
- Abbreviation: EBI, evidence-based intervention.
- Source: Wingood and DiClemente (2008).
Given the need for evidence-based, FASD-informed resources for teachers (Lees et al., 2022), the Families Moving Forward (FMF) program was identified as an FASD intervention that could be efficiently and successfully adapted to teachers. The FMF Program is an evidence-based behavioral consultation program for caregivers of children with FASD, developed at Seattle Children's Research Institute/University of Washington by Heather Carmichael Olson and colleagues (Bertrand, 2009; Olson et al., 2009). The FMF Program is typically delivered in-person or via telehealth in weekly 60-min sessions, or biweekly 90-min sessions, over the course of 6–9 months. Additional consultations and behavioral observation sessions are built in, including a targeted school consultation session. Grounded in developmental and family systems theory and developmental psychopathology, the FMF Program aims to reduce risk factors and enhance protective factors particularly relevant to the needs of people with FASD and their families. Specifically, the FMF Program incorporates concepts such as psychoeducation, reframing, positive behavior support (PBS), and accommodations (see Section 1. Theoretical Framework in the Methods section for theoretical grounding and logic model of the FMF Program).
Multiple trials have shown the FMF Program has significant effects on family outcomes, including increased parenting self-efficacy, parent self-care, knowledge of FASD, and family needs met, as well as decreased child disruptive behavior (Bertrand, 2009; Olson & Montague, 2011; Petrenko et al., 2017). To increase the scalability and accessibility of the FMF Program, the FMF Connect mobile health (mHealth) app was derived from the standard FMF Program. FMF Program material was adapted for a digital format and is delivered in self-directed Learning Modules in the app. Additional components were added to FMF Connect, including a Library with additional resources and videos, a Notebook to store tools and resources, a Family Forum for caregivers to connect with one another, and a behavior tracker tool, which caregivers use to track their children's behavior (Petrenko et al., 2020). Trials of FMF Connect indicate the technology and intervention are acceptable to caregivers and preliminarily signal positive results in family outcomes (Petrenko et al., 2020, 2021; in prep). Given their focus on risk and protective factors across settings and successful digital adaptation, the FMF Program and FMF Connect provide an ideal basis for developing an FASD-informed intervention for teachers.
This study describes a needs assessment conducted with teachers and conclusions about the fit of a website adaptation of the FMF Program for this population, consistent with the first two steps in the ADAPT-ITT framework: Assessment and Decision. Decision traditionally involves reviewing all existing EBIs and selecting the best fit based on the needs assessment. However, FASD-informed interventions are limited, and the majority include a child component (see Reid et al., 2015 for a review). Because we aimed to develop a scalable and self-paced digital intervention targeting teachers only, we excluded interventions which included a child component (e.g., MILE; Coles et al., 2009; Kable et al., 2015). We selected the FMF Program as the intervention to be adapted over other FASD-informed interventions given (1) our lab has extensive experience adapting the FMF Program to a digital format in FMF Connect (Petrenko et al., 2020, 2021; in prep); (2) we will focus exclusively on teachers, rather than on child outcomes; and (3) several FMF Program concepts, such as PBS and accommodations, are generally already established in schools. We selected a website delivery over an app, given the greater flexibility of a website to be accessed across platforms. Thus, our aim for the Decision step was to evaluate the goodness of fit of a website adaptation of the FMF Program for teachers.
2 PURPOSE
- 1.
What are teachers' needs for an FASD-informed resource? (Assessment)
- 2.
How do teachers perceive the content and principles of the FMF Program and FMF Connect? (Decision)
3 METHODS
3.1 Theoretical framework
The current study was informed by the theoretical framework underlying the FMF Program and the FMF Program logic model (see Figure 1; Bertrand, 2009; Olson et al., 2009; Petrenko et al., 2016; Petrenko et al., 2017). Developmental and family systems theories posit risk and protective factors at the individual, family, and societal levels, including factors such as biological characteristics, parent–child relationship support system, and stigma and discrimination.
These factors are connected and targeted using the FMF Program logic model. This logic model conjectures that lack of knowledge of FASD, due to lack of widespread education and awareness of FASD, may lead to misinterpretation of behaviors associated with FASD. Without appropriate understanding of neurodevelopmental challenges, difficulty with executive functioning, language and social communication, and emotional and behavioral regulation may be seen as willful misbehavior, rather than stemming from a neurodevelopmental disorder. Attribution theory (Weiner, 1980, 1985) holds that if behavior is willful, a consequence or punishment is seen to be appropriate. Thus, lack of awareness and understanding of FASD and associated misinterpretation of behavior may lead to unnecessary punishment and stress, and in turn feelings of low efficacy and a negative parent–child relationship. The FMF Program targets these risk factors using psychoeducation, attribution modification, PBS, and accommodations. Psychoeducation refers to basic education about mental health and related challenges and is used to help caregivers understand more about FASD and how their child's behaviors are related to FASD. This in turn supports attribution modification, or encouraging caregivers to use “reframing.” This means understanding that the child's behaviors result from an underlying brain-based disability, rather than from willful misbehavior. The FMF Program specialist helps the parent to create a behavior plan based on PBS, a behavioral intervention style which involves analyzing a behavior to understand its function and provide replacement behaviors to meet the same need. Accommodations, or antecedent-based behavior strategies, are implemented to support the new (replacement) behavior and help prevent the old behavior before it happens.
3.2 Study design
3.2.1 Participant recruitment and study procedure
Convenience and criterion sampling was used (Marshall et al., 2022), in which teachers who responded to recruitment advertisements and notices were included if they met eligibility criteria. Participants were recruited nationally through several sources. First, parent participants involved in previous FASD research, all of whom have children with confirmed PAE or FASD, received an email informing them about the study and encouraging them to share recruitment materials with their child's teacher, if interested. Teachers were also encouraged to forward information about the study to others who may be interested and eligible. We also directly targeted teachers and school staff through national email newsletters and social media forums.
Interested participants were directed to click the study link, which directed them to the study REDCap site where they gave informed consent and completed questions related to eligibility. To be eligible, participants must have been (1) 18 years of age or older; (2) currently employed in a school setting teaching children in grades preschool to 12 (P-12); and (3) have taught a student with FASD either in the past or currently. If eligible, participants were directed to demographic surveys and were contacted via email to schedule an interview. Sixty participants consented, 38 of whom were eligible and contacted for an interview. A total of 23 teachers completed an interview. Scheduling difficulty was the primary reason eligible teachers did not complete interviews. No participants withdrew during the interview. The study team reviewed data saturation and determined the sample size was sufficient; thus, recruitment was stopped.
The current study took place entirely online. Participants were interviewed via secure Zoom videoconferencing. Given the virtual nature of the interviews, participants were free to join from wherever they were most comfortable, most often from their home, classroom, or office, allowing for the participant to be in their natural setting. Observation of participants was limited to the interview. Only the interviewer and the participant were present for interviews unless the participant was in a space with others present (e.g., in their classroom). When this was the case, interviewers noted the presence of others and participants were encouraged to find a private space if possible, but were allowed to continue with the interview if they chose.
3.2.2 Interviews
Interviews took place from April to June 2021. Each participant was interviewed only once, by one interviewer. The interviews were semi-structured and conducted by a team of four interviewers, including the first and second authors, as well as a research assistant and a project coordinator in the lab. All interviewers identified as female and had obtained at least a Bachelor's level degree, with two interviewers (including the first author) holding a Master's degree. All interviewers except one had previously conducted research interviews in the lab, and all had undergone a training in interviewing administered by the lab P.I. (fourth author). Before the interview, no interviewers had relationships with subjects, and interactions with subjects were limited to emails and the interview itself. Subjects were told the reason for the research. See Supporting Information S1: Table S1 for key questions and follow-up questions asked in the interviews.
Interview questions were developed before interviews but were expanded to include additional topics that arose over the course of the study. Interviews lasted for an average of 53 min, 23 s, and ranged in length from 29 min, 22 s to 81 min, 57 s. Interviews were assigned to each interviewer in proportion to the interviewer's level of effort available for the project. Thus, averages may be skewed. Total number of interviews and mean duration of interview by interviewer is as follows: interviewer CK: 14 interviews, average duration 48 min, 27 s; interviewer AR: 4 interviews, average duration 67 min, 14 s; interviewer ES: 3 interviews, average duration 39 min, 43 s; interviewer SZ: 2 interviews, average duration 46 min, 19 s.
Participants were asked what training they had received about FASD and what they needed in an FASD-informed website intervention. They were also asked about motivators and barriers to using an FASD intervention website. Finally, they were presented with content from the FMF Program and FMF Connect and asked for their opinions on the content. Interviewers used open-question interviewing techniques to elicit further discussion (e.g., “can you tell me more?”) and were encouraged to utilize interview questions flexibly to maintain a conversational feel.
Interviews were recorded using Zoom videoconferencing and transcribed verbatim by Execuscribe. Transcripts were checked by the first author for accuracy but were not checked by participants.
3.2.3 Field notes and interview memos
Interviewers took minimal field notes during interviews; these served largely to note a topic to follow up with later in the interview. Interviewers' impressions and notes were recorded in methodological memos completed after the interviews were complete. Methodological memos served several purposes, consistent with Marshall et al. (2022). The first was to record notes and observations about participants during interviews, such as attention, engagement, tone, affect, and so on. Another purpose was to understand themes and patterns as they arose in the data. Researchers recorded and discussed preliminary themes of interviews and their own initial understanding of the data.
3.2.4 Researcher role and positionality
As noted above, given the virtual nature of the study, interaction with participants was limited to the interview. The researchers were unable to observe or participate in the setting.
All researchers in the study come from a background in research and clinical work with caregivers of children with FASD, and all have significant experience with children with FASD. Given frequently reported tension between caregivers and schools (e.g., Petrenko et al., 2020), researchers purposefully and frequently discussed their biases and expectations around the teachers' perceptions and experiences during interviewing and data analysis stages. The research team also had significant experience with research around stigmatizing language and discrimination against children and adults with FASD, as well as reasons for PAE, and were sensitive to their own reactions and emotions when these issues emerged during interviews and analysis.
One researcher on the team was previously a teacher and had related insight into educational practices. The majority of the research team identified as white and non-Hispanic, with one interviewer identifying as Asian; all researchers were aged 24–27 and were assigned female at birth. Four of the five researchers identified as female, with one identifying as nonbinary. These demographic characteristics may have introduced biases related to gender, racial, and ethnic differences as well as generational differences. Researchers made an effort to understand and vocalize these biases, and results should be interpreted with these in mind.
3.2.5 Ethical considerations
All study procedures were approved by the University of [redacted] Institutional Review Board. Participants were informed that they could withdraw from the study at any time and their data would be deleted. They were also informed that they could skip any question in the interview and it would not affect their participation in the study. Any identifying information in interview transcripts was redacted.
3.3 Data analysis and analytic framework
Data analysis combined a phenomenological approach (used in the study design) with qualitative content analysis. The aims of the present study were not only to understand teachers' lived experiences but also to use results to understand their needs and inform an intervention. Therefore, we aimed to use a phenomenological approach to understand the essence of their experience (Marshall et al., 2022) and qualitative content analysis to select and focus on key aspects of the data, interpreting meaning from the content of these data (Hsieh & Shannon, 2005; Schreier, 2012). Consistent with a phenomenological approach, interviews were analyzed individually and then compared across participants to understand the shared experience. Guided by this goal, the steps of qualitative content analysis were used as recommended by Schreier (2012).
First, the main categories of the coding frame were identified based on the research questions. Then, subcategories were inductively formed based on the data during a pilot phase. These categories and subcategories were refined through discussion among three coders (first, second, and third authors), then all interviews were coded (interviews coded in the pilot phase were re-coded). All coders coded all interviews, and any discrepancies or questions related to coding were discussed until coders reached a consensus. During the process of coding, codes were added to the codebook. Once coding was complete, participant matrices and code-co-occurrence tables were used to understand relationships between code categories, subcategories, and participant demographics. Themes were inductively derived from the data.
Data and codes were managed using Dedoose Version 9.0.62 (SocioCultural Research Consultants, 2022). All code co-occurrence and demographic analyses were conducted using Dedoose. Participants did not provide feedback on the findings. Coding schema and coding book are available upon request to the corresponding (first) author.
Excerpts from participant interviews were selected by the three coders and all coders agreed on the representative quotations. Quotations were selected based on their clarity and conciseness in illustrating a theme or subtheme. Quotations were also selected to fairly represent all points of view as much as possible.
3.4 Quality and trustworthiness
Qualitative research establishes trustworthiness through triangulation, credibility, confirmability, and transferability, as discussed below.
Triangulation: Creswell and Miller (2000) offer four types of triangulation, which are methodological, data sources, theoretical, and investigators. The current study establishes theoretical and investigator triangulation. The positioning of results in the context of developmental and family systems theories, attribution theory, and developmental psychopathology indicates theoretical triangulation. Investigator triangulation is established by the presence and analysis of multiple investigators on the team, each with different theoretical and experiential backgrounds (Creswell & Miller, 2000). Investigators provided different observations and interpretations of the data. Additionally, the results of the current study have theoretical sufficiency (Marshall et al., 2022), or well-described and flushed-out categories for the data. Along these lines, disconfirming cases were sought out and included in the results and analysis.
Credibility: Credibility is established in the current study based on rigorous methodology and researcher credibility (Marshall et al., 2022). Data was gathered from diverse participants and is thought to represent the experiences of those interviewed. Additionally, research reflexivity, the process by which the researchers reflect on their biases and assumptions, contributes to credibility and was documented in analytic memos.
Confirmability: As noted by Marshall et al. (2022), qualitative study results being directly confirmed by another study is unachievable; however, investigator triangulation and disconfirming cases serve to increase the strength of the results. Additionally, the study's methods and results are presented in depth, lending transparency to the results and enabling outside researchers to understand and verify them.
Transferability: Transferability, or usefulness to others in similar situations, is established in the current study by rigorous methodology and theoretical grounding. While qualitative studies typically should not be considered generalizable to other populations (Marshall et al., 2022), the current results will be useful to researchers aiming to understand teachers' experience with students with FASD. Additionally, the findings will be used to inform a resource for teachers, thereby contributing to FASD-informed care and the broader FASD intervention field.
4 RESULTS
4.1 Participant demographics
Demographics are presented in Table 2.
| N | % | |
|---|---|---|
| Job title | ||
| Special education teacher | 17 | 73.91 |
| General education teacher | 5 | 21.74 |
| Othera | 1 | 4.35 |
| Years of experience as a P-12 educator | ||
| 0–4 years | 3 | 13.04 |
| 5–10 years | 8 | 34.78 |
| 11–15 years | 1 | 4.35 |
| 16–20 years | 4 | 17.39 |
| 21–25 years | 5 | 21.74 |
| 25 years or more | 2 | 8.70 |
| Education | ||
| Bachelor's degree | 5 | 21.74 |
| Master's degree | 4 | 17.39 |
| Education or credits beyond Master's degree | 14 | 60.87 |
| Grades currently taught | ||
| Preschool | 2 | 8.70 |
| Elementary | 12 | 52.17 |
| Middle | 4 | 17.39 |
| High school | 2 | 8.70 |
| Transition | 2 | 8.70 |
| Geographical location | ||
| Rural | 8 | 34.78 |
| Suburban | 9 | 39.13 |
| Urban | 6 | 26.09 |
| Approximate number of students in school | ||
| 100 or less | 1 | 4.35 |
| 101–250 | 5 | 21.74 |
| 251–400 | 5 | 21.74 |
| 400 or more | 12 | 52.17 |
| Reliable access to internet in classroom | 23 | 100.00 |
| Gender | ||
| Female | 21 | 91.30 |
| Male | 2 | 8.70 |
| Race/ethnic group | ||
| White | 19 | 82.61 |
| Asian | 0 | 0.00 |
| Black or African American | 1 | 4.35 |
| Native American/Pacific Islander | 0 | 0.00 |
| Other | 1 | 4.35 |
| Do not wish to respond | 1 | 4.35 |
| Ethnicity | ||
| Not Hispanic/Latino/a/e | 19 | 82.61 |
| Hispanic/Latino/a/e | 2 | 8.70 |
| Do not wish to respond | 1 | 4.35 |
- Abbreviation: FASD, fetal alcohol spectrum disorders.
- a One teacher was employed as a coach at the time of the interview but was a certified teacher with experience teaching children with FASD, so met eligibility criteria and was included.
4.1.1 What are teachers' needs for an FASD-informed resource? (Assessment)
Overall, teachers were positive about the idea of an FASD-informed resource and many felt they had a significant need for information and resources on FASD. Few (N = 5, 22%) reported receiving formal training about FASD, which included reviewing basic information about FASD while completing their undergraduate degree or teaching certification. The vast majority (N = 18, 78%) reported being educated about FASD by a parent or another teacher or seeking out information on their own (e.g., using Google). They expressed concern about the lack of readily available information about FASD, especially as they felt it negatively impacted both teachers and students. Teachers were especially passionate about adverse effects on students; many emphasized their desire to see their students succeed and their frustration that they felt ill-equipped to support them.
Thus, teachers felt an FASD-informed intervention was needed. They discussed specific needs and considerations around this resource and provided many suggestions and recommendations. These suggestions were thematically organized into four categories: format recommendations, language and content considerations, feature recommendations, and content recommendations (see Table 3). Teachers also discussed methods of distributing the website, noting they are likely to ignore emails or advertisements from organizations with which they are not familiar. They supported the idea of the website being distributed through existing organizations and lists, and hearing about these resources from other teachers.
| Category | Description/definition | Suggestions |
|---|---|---|
| Format recommendations | Suggestions about the format of the website, including accessibility, delivery, and appearance |
|
| Language and content considerations | Recommendations for the language and content of the modules and resources |
|
| Feature recommendations | Suggestions for features to include in the website |
|
| Content recommendations | Specific content and strategies to include in the materials |
|
- Abbreviation: FASD, fetal alcohol spectrum disorders.
Additionally, when discussing teachers' needs for an FASD-informed resource and considerations that should be taken into account, three overarching themes emerged: teachers need specific information and resources related to FASD, teachers have very little time, and the needs of special education teachers and general education teachers differ.
4.1.2 Teachers need specific information about FASD and strategies to support students with FASD
Teachers reported frustration around the lack of FASD-informed resources available to them. They called for specific content and features to address their need for both basic and specialized information. Basic information on FASD was one of the most commonly identified needs, with many teachers noting they would benefit from information on what FASD is, how it is diagnosed, and how it might present in a student. However, they also stated they need specialized information, for example, resources on co-occurring conditions, trauma, out-of-home placements, and adoption. They also expressed a desire to understand their students' behaviors as resulting from FASD rather than from willful misbehavior, and they spoke to the need for education about challenges in FASD to support this understanding.
Teachers also felt ill-equipped to support their students, especially in the context of challenging behaviors such as impulsivity and difficulty with self-regulation. Accordingly, they called for strategies to support de-escalation and calming, executive functioning, and sensory sensitivity. They also reported a need for information about alcohol exposure during pregnancy, both for their own education and to better communicate and work with caregivers of children with FASD. Finally, teachers wanted to be able to share content with other teachers and requested content that would be easily shareable and useful across a wide variety of contexts. For example, some noted that their students with FASD had challenges in settings outside of their classrooms, like the bus, and recommended content and strategies to support the student that would be appropriate to share with a bus driver or aide.
Not only did teachers report a need for FASD-informed content and strategies, but they also emphasized that the information in the resource must be readily applicable to real life. Some noted they had sought out information about FASD from other sources, such as Google, but struggled to glean takeaways from the materials that would help them in the classroom. Teachers also described students with FASD as heterogeneous in their presentation in the classroom, so they needed a resource to support them as new challenges arose. One noted, “[a student with FASD] keeps me on my toes, so I'm constantly looking for ideas and things, and I'm constantly talking to his parents … I think that's [one] reason I keep on top of figuring out strategies for FASD” (Participant 32). Many indicated a preference for video examples of the strategies being demonstrated to increase further practicality and immediate uptake: “You know what, in all honesty, I think videos of kiddos who are performing the action you want the teacher to see, that's how I learn the best. I need to see it so I can recognize it. Doing that in vivo is difficult but via video training, if you can get parents to agree to it, is huge” (Participant 20).
Evidence-based information and strategies were a vital need brought up by several teachers. Some noted that in seeking out information for themselves they were not sure what information was backed by research and what was not: “I was looking at my own, you know, research and looking up things online, and you don't know if that's always truthful information. That's the problem” (Participant 45). They emphasized the need for content and strategies backed by evidence for several reasons: evidence-based strategies would be more likely to be effective, would save them time, and would be more compelling to the administration and other teachers. One noted, “if there's research that shows it works and it's going to benefit the kids greatly for these reasons, the schools will do it” (Participant 51). Teachers pointed to advocacy as another important factor in why they would be drawn to the website; they wanted the ability to share FASD resources and information with other teachers and to spread awareness through staff trainings as well as to administrative boards, counties, and professional learning networks. Discussion of evidence-based strategies often overlapped with not having enough resources in the first place, wanting to teach others, and wanting new knowledge/ideas surrounding FASD.
Consistent with this theme, when asked what would motivate them to use an FASD-informed resource, teachers most commonly stated gaining new knowledge about FASD and ideas for supporting students with FASD. This was reported by over half the sample (17 teachers, 74%). Also aligning with the theme of needing information on FASD, teachers frequently cited having a student with FASD in their classroom as a motivator for utilizing the resource. Many felt they would use the website to understand more about the disorder, and this often co-occurred with the idea that there are not enough resources on FASD for teachers in the first place. Others felt simply knowing such a resource exists would motivate them to use it, given so little about FASD is available: “I think having the option, first of all [would motivate me] … we all want our kids to be successful and I think that would be one of the things doing that. So, I think, you know, I think it being available is going to be a plus, it really is. I think it's going to be very helpful” (Participant 16).
Although teachers emphasized their need for information specifically on FASD, they recognized that some teachers would not use an FASD-informed resource for that very reason. Participants felt that many teachers, especially general education teachers, may need to see the information as applicable to all students to be motivated to use the website: “[General education] teachers, you know, their training and their expertise is really about supporting the 97% … Whereas, you know, FASD is not in the 97%” (Participant 56). Others felt the stigmatization that comes with FASD itself might be a barrier to using the resource, as they did not want to cause offense or be the reason for a child or family to experience stigma. One noted, “I feel like there is such a stigma behind FASD, so if you found a resource … making sure that a lot of the writing and printed materials and stuff, it's not like ‘FASD’ … making it a little more discreet so if it is out on your desk or if you're sending something home that you saw, you're not necessarily insinuating anything or bringing that fact to light” (Participant 7). Concerns of stigmatization were more often raised by general education teachers than special education teachers.
4.1.3 Teachers have limited extra time, so a resource must be concise and easy to use
Throughout interviews, teachers emphasized their need for a resource that was easy to use, concise, and practical, given they had little extra time. Many teachers talked about juggling multiple demands, especially when they were understaffed or had larger class sizes, something exacerbated by the COVID-19 pandemic. Teachers frequently expressed negative emotions related to having little time, such as frustration and burnout. Thus, many recommendations had to do with making the website easier to use and facilitating faster access to information.
Teachers strongly recommended the content of the website be quickly accessible and brief. Many stated they did not have time to spend in a professional development course or sift through lengthy, in-depth information. They recommended content be short and easily digestible, with some suggesting the use of bulleted takeaways. Teachers suggested modules and videos be kept to a maximum of a few minutes in length. One said, “For me, personally, when I see something and it's going to be multiple pages of just reading text, I'm like, ‘Okay, I'm tired.’ [laughs] I can see it, I don't mind reading. Obviously, I like reading, but I just find it more engaging if there is like may be a brief kind of background and then of what the video is going to be and then go to the video, and somebody using the strategy” (Participant 18).
Because teachers were already having to invest significant time into researching FASD, given how little opportunity they had for training, they felt having one evidence-based resource on FASD would save them time: “As an educator, I don't have a lot of time to go look for other stuff, so just having something there to just click on and go I think would be really helpful” (Participant 24). By far, the most common barrier to engaging with an FASD-informed intervention was a lack of time, with 12 (52%) teachers noting they would not engage with the resource if it were overly time-consuming. They noted that their recommendation for practical content (described above) would also save them time: “And then, really, simplified and to the point. There are so many different apps and things that they want us to use now and a lot of those tend to have extra nonsense on there that nobody really needs so clear, simple to the point, easy to use, and beneficial” (Participant 25).
Teachers also discussed a desire for a resource to save them time by simplifying tasks they already had to accomplish, such as supporting challenging behaviors, preparing lessons, and writing Individualized Education Plan goals. They felt this would be a motivator for teachers using the website, with one saying, “if [teachers] can see how by using the resources that you are offering, they can set up the classroom just so, before things actually get to that point where you're having to stop what you're doing to intercede, you know, for behaviors or conflicts or, you know, off-task behaviors. So, just like I said, really setting it up front that if you do all of these things, you're going to save yourself time down the road” (Participant 17). Along these lines, teachers recommended that anything required for strategies on the website be provided so they could print out materials they need rather than create them on their own, which would also save them time. One participant noted, “So, if there's a strategy … or if you recommend collecting data a certain way, if you give me the materials for doing that, that is huge because it's just one less thing that I have to try to find the time. And if I have to try to find extra time, it's less likely for me to use your intervention” (Participant 18).
Teachers also suggested aspects of the layout and navigation of a website that would make it easier to use and more efficient. Design aspects of the website, such as being engaging and easy to access, were cited as motivators to use a resource by multiple teachers. Many felt that difficulty using the website would be a significant barrier. Teachers expressed concerns surrounding having to click through multiple pages to find information: “[Whether I would use the website] would depend on how well designed it was, if you have to click through a lot of things and it's very time consuming or confusing” (Participant 30). Themes of difficulty of use, a confusing layout, and having too many options to click through were often brought up together. They felt that allowing the website to be self-paced would support their ability to find what they need immediately. They also felt the website should be accessible across various platforms by people with varying degrees of comfort with technology. They noted that difficulty learning how to use the website would be a potential barrier. They brought up concerns regarding the technology and accessibility to all teachers: “For me being older, it would be can I navigate the website? If I go into something and I can't find something easily, I'm not going to use it. I'm going to click out and find something else that's easier to use” (Participant 29).
Teachers also pointed out that while some would be intrinsically motivated toward learning about FASD and using a resource, others found extrinsic factors like certificates motivating, especially given many teachers are required to complete continuing education credits. Teachers felt the resource should be able to fit into their existing schedule rather than requiring additional time and resources to use. Several noted that they spend 10–15 min before or after school researching strategies, as well as having weekly or monthly staff training sessions, and suggested they would incorporate the resource into this time. Four teachers also brought up cost being prohibitive as teachers are not given funding for their classrooms nor appropriately compensated for their time. This common theme was generally endorsed by teachers in urban schools and was not mentioned by teachers in suburban or rural schools.
4.1.4 Teachers' needs vary depending on their training, experience, and setting
Teachers also noted that the training they receive varies, often having to do with their role (i.e., special education or general education), and emphasized that an FASD-informed resource must be relevant to different levels of experience. They also described varying needs for diverse settings; most notably, large class sizes.
Teachers discussed the differing types of training and levels of expertise afforded to different teachers. Some teachers (e.g., special education teachers) receive extensive training in disabilities and behavioral supports. Thus, teachers recommended that the website be suitable for people with a high level of expertise, with one saying, “any time I look up FASD stuff, it's more like the overview stuff … it's geared towards teachers but—I know it's not meant to be insulting, but it just gets annoying after a while seeing stuff online that's like, use a visual schedule, use clear expectations. I know, obviously I'm doing that … ‘Don't use punishment.’ It's like, ‘Yeah. We know not to use that.’” (Participant 48). Others pointed out that some teachers, especially general education teachers, receive little training in supporting students with disabilities. One special education teacher said, “if I'm looking at it and you put confabulation, I know exactly what I'm looking for. If a general education social studies teacher sees that word, he or she might have no clue. Bearing in mind the wording in regard to whether you're targeting specialists or general education teachers” (Participant 30). Due to this, teachers specifically called for strategies that would be feasible for teachers with less training. They emphasized methods of delivering content that would be clear and easy to understand, such as video examples.
Several ideas were suggested to address these issues. Teachers suggested providing a difficulty rating to indicate the experience and time needed to execute a given strategy. A “placement test” was recommended to give teachers a sense of their previous experience with the content and allow the website to offer strategies suited to their level of expertise and setting (e.g., class size, classroom type). Teachers noted these types of features would be helpful for teachers without specific training in supporting students with disabilities and new teachers who have less overall teaching experience, as well as for teachers with a high level of expertise.
“… it might be more motivating for [teachers] if it were information that would be if it was framed in a way where it would support your student with FAS, but it also is a great way to support all students. You know, somehow to tie it into that because I think that a lot of people are stressed for time and if they have just one student with FAS, they're going to be less likely to be motivated to seek it out … trying to gear it towards like, ‘This is good for all students.’ And it happens to be an evidence-based practice for students with FAS” (Participant 18).
“[My student] has on his IEP like he needs to be seated in a location with minimal distractions. And so, what the PE teacher thinks that means and what the science teacher thinks that means are completely different … I think anything about kind of norming on what modifications and accommodations, how to make those actually work, is important” (Participant 39).
4.1.5 How would teachers use an FASD-informed resource?
Three patterns of use of an FASD-informed resource emerged throughout the interviews: proactive use, reactive use, and using it as a training resource with other staff in the school. Some teachers felt they would proactively use a website, motivated by having a student with an FASD in their classroom. This would be to learn more about the condition or gain new ideas for classroom strategies: “I would find myself reaching out to the website for preventative ideas. If I know that we may experience a problem in the near future with certain activities that are difficult for them or hurdles that we might come across, I'll try and get strategies ahead of time so I'll use that as a preventative source” (Participant 32). Generally, teachers who expected proactive use of the website stated they would visit the website occasionally, saying they would log on once a week, during after-school hours, or as a refresher: “I see myself using it after work hours, just like dabbling around, learning more” (Participant 10). Proactive use was almost exclusively stated by special education teachers compared to general education teachers.
Others felt they would reactively use the website to respond to certain behavior challenges in the classroom. Teachers emphasized that knowing the resource is available when their usual strategies are not working would motivate them to use the site: “I would also definitely use it if I feel like I'm running up against a wall. If I have a student that is presenting in a way that I haven't seen before, or if I've used the tools that are in my back pocket and what I'm doing isn't working … just because you've been doing this for a decade doesn't mean kids don't walk in the door looking entirely different from anything you've seen before” (Participant 30). Teachers emphasized the need for the information to be easy to access given the specific needs of students with FASD: “especially with these kiddos because it's so on the fly and it can change so quick” (Participant 20).
Finally, teachers said they expected to use a website as a training resource with other staff in the school. For example, four teachers endorsed the use of the website as a formal staff training option, with one noting, “If I had a teacher, a new teacher who we knew that they were going to have students in their class, we would say, ‘This is a great resource. Why don't you preview some of the things that you can expect from that child?’” (Participant 33). Others noted sharing the website with staff who worked with students with FASD: “It would definitely be something I would recommend to all people that worked with the student. I would definitely go to it to pull resources and things” (Participant 59). Teachers emphasized their need for materials to train their classroom support staff and other teachers in the school, particularly given that FASD is a hidden disability (meaning it often presents with no visible features) and individuals with FASD are often very different from each other. Compared to general education teachers, special education teachers more often expressed wanting to train others.
4.1.6 How do teachers perceive the content and principles of the FMF program and FMF connect? (Decision)
FMF program concepts
Teachers were asked their opinions about the concepts taught in the FMF Program, specifically PBS, accommodations, psychoeducation, and reframing. They generally felt positive about these concepts, and many had already implemented them in their classrooms. In some cases, such as PBS and accommodations, teachers had been formally trained on the concepts and deliberately applied them. In others, especially reframing, teachers had not been formally trained on the concept but provided examples of using it in their own classroom. Teachers also brought up challenges in teaching and adopting these ideas in the classroom.
PBS (also referred to as Positive Behavior Intervention Support or PBIS) and accommodations were often well known to teachers, especially special education teachers, and were generally positively received. Teachers especially endorsed PBS: “my entire program is based on PBIS … in general, that is I think the best thing I've ever done in my room” (Participant 57). Some teachers described using specific PBS-based curricula, e.g., “Boys Town” (Fluke et al., 2013), while others talked about using PBS in their classroom to understand and support behavior challenges by finding antecedents and functions of behavior. PBS was almost exclusively used by special education teachers and was generally a strategy used in the entire classroom, not just for students with FASD. However, some teachers described challenges using PBS for students with FASD, given their difficulty with impulsivity, memory, and self-regulation: “Especially with like PBIS and behavior interventions, that it works for a little bit and then you know, you reason with them, you talk to them, you make repairs and then the next day they do the same thing because they either don't remember the conversation, it doesn't click, the motivation isn't there or the impulses get in the way” (Participant 48).
A significant challenge for teachers in using PBS and accommodations is a lack of support: “I mean, it takes time and I have three aides in my room. If it's a strong aide, it's good because you can kind of tell them and it'll stay and that'll be something that they're handling, but if it's not, then it kind of falls through the cracks sometimes” (Participant 7). Another challenge noted by teachers was that not all teachers receive training on PBS, and staff such as board-certified behavior analysts, who often conduct functional behavior assessments and support teachers in PBS, are extremely limited.
Generally, teachers were not familiar with the terms psychoeducation and reframing but felt that these concepts would be helpful for them in the classroom. Teachers felt psychoeducation about FASD would help them to understand what to expect from students with FASD and how to support them. This aligned with identified themes around teachers' need for information about FASD. Teachers also felt reframing would be helpful, describing benefits for both the student and the teacher. For example, one teacher noted that reframing student behavior would allow better behavioral strategies to be used and lead to more success: “You know, if I'd had someone that taught me in a [professional development course] that, you know, if you see a child showing signs of extreme anxiety, that person, chances are, is not just seeking attention in a negative way. They really are struggling with something, and then you can start to offer interventions, you know, fidgets, walking breaks, movements” (Participant 17). Teachers also noted reframing would help them regulate their own emotions: “And you know, that would be a resource that you could go to every time that you were feeling discouraged or someone seemed to get a little overworked by a kid, you can be like, ‘Oh yeah, let's look at this one again’, you know?” (Participant 7).
Although few teachers were familiar with the term “reframing” used in the FMF Program, many teachers were familiar with the idea and gave examples of reframing in the classroom. One said “I don't know if I explicitly learned it, but … I just have to keep in mind that, you know, I know she's not trying to manipulate me. I know that she is overwhelmed or she's tired or something, and this is how she's responding because of that” (Participant 15). Many provided spontaneous examples of reframing they have done in the classroom. They also drew contrasts with their colleagues who had had limited training or experience with FASD. One said “I still see so much of the attitude of blaming, blaming. ‘Well, if they'd just do this …’ There's so much of the time they can't just do that” (Participant 4). Other teachers provided willful explanations for behavior: “[The school psychologist] kind of gives her all this positive reinforcement, and this student loves that positive reinforcement. So, in my mind I was like, ‘Oh no. I shouldn't have called [the school psychologist] because now [the student's] going to do this every time and want that positive reinforcement’” (Participant 15).
Some explicitly connected reframing to the availability of training in FASD: “Most teachers don't have an understanding. They just think the kid is either being lazy or, you know, they have some other issues. They're not relating it to that the students' brains fire differently. Their synapses in their brains. It's just not the same” (Participant 29). They even described their own experience as they educated themselves about FASD: “I didn't know much about [FASD]. So, like when I was reading through some of the things, they're like, ‘You might think she's being defiant,’ and in my head I'm like, ‘Yeah.’ You know, ‘you might think this’ and I'm like, ‘Yes, I do.’” (Participant 15).
“The problem is there's just no time. I know the teachers, they want to support the kids … I think that's really hard as that trying to get the other teachers to see that it's like a ‘can't do’ not a ‘won't do’ situation where they might see it as behavior. I have to do then the advocacy of like, ‘Well, no. His brain is literally not wired to listen to you or to take in your information’ or ‘He can't sit still for more than 5 min.’” (Participant 48).
This is a challenge to reframing, especially in larger class sizes; this participant continued: “Then also in the moment in the classroom, when you have 25 other kids and you don't have the time to sit down like, ‘Oh, well so-and-so did this. I wonder what is [the function]? Attention? Tangible [reward]? That's what's hard’” (Participant 48). Others connected willful explanations of behavior and difficulty reframing with the fact that FASD is a hidden disability, describing “individuals who do not have the facial features, who are on the spectrum because of prenatal exposure, but they are just high-flying enough that people don't understand why they're not being successful” (Participant 11).
FMF connect components
Teachers were shown screenshots of the FMF Connect app (see Figure 2) and asked specifically about the components of the app, including the Notebook, Learning Modules, Library, Dashboard, and Family Forum, and whether they felt each component would be relevant and appropriate for teachers.
They felt positively about the overall look and feel of the app, with one teacher saying, “And I think the graphic design, the way you had that set up, it was very appealing, and I am so old school I'm very intimidated by technology, so that was not intimidating at all. It was very inviting” (Participant 24). Teachers felt positively about the Notebook, Learning Modules, and Library, expressing that the content, resources, and tools would be not only helpful for their own learning but also for training others. They appreciated the brief length of the content in the FMF Connect app, reflecting themes around the need for information on FASD and lack of time. They were especially enthusiastic about the idea of a video library (housed in the Library on the FMF Connect app) and noted they specifically wanted to see strategies or concepts being demonstrated in videos. They liked the Notebook's ability to organize materials and tools for them, as well as the content and format of the Learning Modules. No negative evaluations were made about these FMF Connect components.
Teachers reacted positively to the Dashboard, but most discussion in this area centered around the Behavior Tracker, a tool to track children's behavior housed in the Dashboard. Many teachers were enthusiastic about the idea of the Behavior Tracker for student behaviors. Some were already tracking behaviors on paper forms or with other apps and felt they would appreciate doing this on a website, especially if it was easy to use. They felt the behavior tracker would facilitate communication between teachers by allowing behaviors to be tracked across multiple classrooms: “if I could see on that tracker that my student had four anxiety issues in science in a week, that would be a trigger for me to go talk to that teacher and ask ‘What is the project you're working on? How can we collaborate to accommodate his needs and whatever the curriculum is requiring of him?’ As of right now, I don't see those teachers on a regular basis” (Participant 25). Additionally, teachers noted the behavior tracker could support them in analyzing behavior when they were understaffed, a challenge to PBS described above. Teachers often described the behavior tracker as a motivator to use the website.
Teachers also offered suggestions for the behavior tracker, such as having pre-existing behavior options to click, tracking positive behavior, and allowing the student to track their own behavior. Some wanted the Behavior Tracker to go a step further and provide analysis of the behavior patterns to further reduce burden on teachers. A frequent suggestion was incorporating a way to communicate with the student's parents using the website, especially through the behavior tracker. One participant said: “Even if it was a simple note [from the parent] of ‘This is what our day looked like. This is what our morning looked like’ that you didn't have to have over-communication about, but you could be aware” (Participant 33).
Teachers were positive about the idea of a discussion forum, which was also named as a motivator to use the website. Most felt they would use the forum to get new ideas and discover behavior strategies that have worked for other teachers. One teacher said, “When I'm able to ask questions of my colleagues outside of the district, it's so helpful. So, I think having a teacher forum where you can post questions would be great” (Participant 14). Some teachers felt a benefit of the forum would be to find support, saying that sometimes teaching is “a lonely endeavor” (Participant 17).
Teachers also raised concerns about the forum, specifically the time commitment, privacy, and confidentiality. Some felt that participating in the forum, including making a profile and engaging with other teachers, may take too much time. Teachers also discussed issues around privacy and confidentiality, both for themselves and for their students: “I think it would be helpful. You just have to worry about the confidentiality piece … Are names mentioned, that kind of thing, or if it's just a matter of just sharing strategies” (Participant 32).
5 DISCUSSION
The current study interviewed 23 teachers with experience teaching students with FASD about their needs and preferences for an FASD-informed intervention. Teachers made many recommendations for the intervention, including format recommendations, requests for specific content, language, and content considerations, and ideas for additional features. Predicted use patterns included proactive use (when a teacher was assigned a student with FASD in their classroom), reactive use (when a challenge arose), and training other staff. Three overarching themes emerged regarding considerations for an FASD-informed intervention for teachers: teachers have little opportunity to gain information about FASD, teachers have limited extra time, and the needs and experiences of special education and general education teachers differ.
Many participants reported having limited prior knowledge of FASD before having a student with FASD in their classroom and felt that they lacked training in how best to support students with FASD. Though recent work suggests high rates of FASD awareness among educators, these studies also indicate teachers have limited training about effective supports for students with FASD and express a need for more information and education (Boys et al., 2016; Chu et al., 2022). This draws an important distinction between understanding what FASD is, and being able to effectively support students with FASD. Teachers in the current study reported being educated by a parent or another teacher and their own research on FASD, reflecting prior work in educators showing that 40% of teachers had learned of FASD through colleagues and 37% from their own research (Chu et al., 2022). Current results contradict prior research showing that over a third of teachers learned of FASD through “education sessions,” though this could have reflected, as in the current study, a brief overview of FASD during undergraduate education or teaching certification (Chu et al., 2022). Finally, teachers in the current study emphasized a need for evidence-based information and strategies and difficulty knowing whether information they came across was accurate. This reflects results of a recent scoping review which suggested few FASD resources for educators are formally evaluated (Lees et al., 2022). Some research has suggested intervention feasibility and appropriateness are more important to teachers compared to an evidence base (Boardman et al., 2005). Determining which needs and motivations were the most important to teachers was out of the scope of the current study, but results suggest teachers do not see these as distinct. In fact, teachers seemed to associate an evidence base for intervention with more effective and appropriate interventions, suggesting these needs are interconnected.
Current results provide preliminary evidence to suggest the FMF Program logic model is applicable to teachers. This model hypothesizes that for caregivers, increased knowledge of FASD will lead to increased reframing, or understanding the behavior as rooted in a brain-based disability rather than willful defiance, and use of more adaptive behavior supports. These, in turn, will lead to positive outcomes including increased self-efficacy, a more positive relationship with the child, and improved child adaptive behavior (Bertrand, 2009; Olson & Montague, 2011; Petrenko et al., 2017). Teachers in the current study explicitly connected lack of FASD training with challenges in reframing and using accommodations, which they connected to feelings of low self-efficacy and frustration. Teachers felt positively about the FMF Program concepts, and to the idea of reframing in particular. Teachers providing examples of times they have used this in the classroom. They pointed out that reframing would not only help them to better support the student, but it may also help them to regulate their own emotions when in a stressful situation. Recent research echoes this in parents; specifically, parents report using their own self-regulation as a sort of accommodation to support their children and use reframing as a foundation to regulate their emotions (Kautz-Turnbull et al., in prep).
Results indicate teachers would proactively use the intervention if they are aware of a student with FASD in their classroom but would be less motivated to use it if they were not. Though teachers will likely have at least one student every few years as prevalence rates are estimated at 1%–5% (May et al., 2018), given low awareness of FASD and low rates of diagnosis, teachers may not be aware of their student's needs. Thus, increased awareness of FASD and access to diagnostic services are needed to make FASD a priority in teacher education and preparation. It is possible that the use of the website for staff training may help more teachers gain awareness of FASD, potentially allowing them to recognize signs of FASD in their students.
Teachers emphasized they had many demands on their time, something that was unsurprising given research showing they invest long hours and significant energy into teaching. A 2009 study estimated teachers spend 1913 h over a 36-week school year, or an average of 53 h per week, on teaching as well as extra role time, such as student mentorship and coaching (Fleck, 2009). Brown and Roloff (2011) suggest this time commitment, and especially teachers' investment of extra-role time, is associated with higher levels of burnout and diminished well-being. They emphasize that teachers who invest a high level of time outside of their role but do not feel appreciated or see positive change in their students are more likely to experience burnout (Brown & Roloff, 2011). In the context of long hours and limited resources, it is unsurprising that time was a significant concern for teachers in the current study.
Teachers' lack of extra time was a common theme and underlay many identified needs and barriers for an FASD-informed website. Teachers stressed content and strategies provided in the intervention need to be concise and practical, emphasizing their need for material with immediate real-world applicability. Research shows teachers point to efficiency, collaboration, and easy access to practical, effective strategies as priorities when seeking out resources (Jones & Dexter, 2014). Dwyer et al. (2019) found teachers generally prefer informal resources such as Facebook and Pinterest over in-depth, formal resources such as information websites. Consistent with the current results, the authors state this is likely due to teachers' lack of time and need for practical strategies and ideas (Dwyer et al., 2019). Teachers also identified difficulty learning and engaging with the website as a barrier to use related to a lack of extra time.
Discussion also arose about aspects of the website related to technology; specifically, accessibility of a website across platforms and by people with varying degrees of comfort with technology, and a need for personalization and interactive content. Digital intervention development principles can be used to address technological concerns such as these. For example, the effort-optimized intervention model includes a set of principles aimed at increasing engagement with digital interventions by reducing the effort needed to engage with them. These include nurturing salience, making therapeutic activities as effortless as possible, and turning effortful activities into sustainable assets (Baumel & Muench, 2021). Current results suggest these principles may fit well with teachers' needs for efficient, easy-to-use, and engaging material.
Despite some concern about technology, teachers were generally positive about the digital nature of the intervention, consistent with results from existing digital behavior support interventions for teachers, including the Daily Report Card. Online (DRC.O) study (Mixon et al., 2019; Owens et al., 2019) and the Study of Health and Activity in Preschool Environments (SHAPES; Saunders et al., 2019). Results of these studies indicated teachers readily adopted and were able to implement behavioral interventions when trained through a website. Notably, the DRC.O study included face-to-face guidance, while the SHAPES study adapted an in-person intervention to a digital format. However, both studies found teachers could implement interventions effectively and with fidelity.
Differences between special education teachers and general education teachers were a strong theme. While practical information on FASD is limited across all teachers, special education teachers receive significantly more information on disabilities in general, and so have more experience with accommodating and supporting different levels of need (Alexander & Byrd, 2020; Brownell et al., 2005). Special education teachers also tend to be better able to facilitate positive outcomes for students with disabilities (Feng & Sass, 2013), and general education teachers report feeling ill-equipped to support students with disabilities in their classrooms (Lombard et al., 1998; Smith & Smith, 2000). Thus, an FASD-informed intervention must be sensitive to different levels of experience, as well as accessible and adaptable across settings.
With regard to components of FMF Connect, teachers most often pointed to the behavior tracker and the video library as motivation for using the website, which is consistent with parent evaluations of FMF Connect (Petrenko et al., 2020, 2021). Teachers differed from parents in their opinions of the forum, which they generally thought of as a place for additional ideas; parents tend to use the forum for emotional support and connection (Petrenko et al., 2020, 2021). Teachers made few negative statements about the components, and concerns were limited to questions of privacy and confidentiality in the forum and time commitment of certain features.
6 LIMITATIONS AND IMPLICATIONS
The results of this study should be interpreted in the context of several limitations. The first is that, like all research, bias may have been introduced into the study methods and results by the researchers, interviewers, and coders. While efforts were made to reduce the impact of that bias, complete removal of bias is impossible and results must be interpreted with caution. Additionally, given the research team's investment in and experience with the FMF Program and FMF Connect, it's possible the participants were not comfortable giving negative feedback and results may be positively biased.
Limitations associated with the current sample must also be taken into account. Though participants represented diverse school settings, grades taught, and years of experience, other demographics were not well represented in the current sample. Future studies should include more subjects of diverse racial and ethnic background, gender, and geographic area. Additionally, given these participants were required to have had experience with at least one student with FASD to be included in the study, results may not generalize to participants who are not familiar with FASD.
The current study has many important implications for future work. Most importantly, results suggest teachers feel an FASD-informed website is important and would be motivated to use and share it. Results confirm the fit of the FMF Program and FMF Connect for this population and indicate adaptation should proceed following the ADAPT-ITT framework (Wingood & DiClemente, 2008). The results can also inform future work developing FASD-informed interventions for teachers and emphasize teachers' need for FASD-informed curriculum and support. Finally, results offer insight into teachers' needs for digital interventions, which should be taken into account as intervention work shifts toward more accessible and scalable interventions.
AUTHOR CONTRIBUTIONS
All authors contributed to the study conception and design. Data collection was completed by Carson Kautz-Turnbull and Emily Speybroeck. Coding and analysis was performed by Carson Kautz-Turnbull, Emily Speybroeck, and Madeline Rockhold. The first draft of the manuscript was written by Carson-Kautz-Turnbull and all authors commented on all versions of the manuscript. All authors read and approved the final manuscript.
ACKNOWLEDGMENTS
All or part of this work was done in conjunction with the Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CIFASD), which is funded by grants from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Additional information about CIFASD can be found at https://cifasd.org. Research reported in this publication was supported by the NIAAA of the National Institutes of Health under Award Number U01AA026104. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Authors would like to thank the teachers who participated in the study for their time and insight. We would also like to thank Shuo Zhang and Alicia Roth who conducted interviews for the study. This work was made possible by the generous support of Rev. Nancy D. Stevens and Mr. David L. Williams.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ETHICS STATEMENT
Informed consent was obtained from all individual participants included in the study.
Open Research
DATA AVAILABILITY STATEMENT
Research data are not shared due to the potentially identifying nature of qualitative interview transcripts.
