Perseveration refers to difficulties making transitions, shifting topics or thoughts, or moving on from one emotional state to another. Some people describe it as a tendency to "over-focus" on a subject. Neurologically related to brain damage in the frontal lobes, perseveration is a common characteristic of persons with FASD. Many FASD-affected individuals may "get stuck" (perseverate) so severely that it interferes with learning and staying on-task, or their ability to shift calmly and without prompting among topics and activities. Perseveration makes it difficult for persons with FASD to function appropriately at school, at home, or in the community.
Experts who study the relationship between brain damage and behavior describe three types of perseveration:
- "Stuck-in-set" perseveration: The uncontrolled and extended maintenance of a thought, activity, emotion, problem-solving strategy, or topic of conversation
- Recurrent perseveration: The uncontrolled repetition or recurrence of a word or phrase when it no longer contributes to meaning. (Verbal "tics")
- Continuous perseveration: The uncontrolled and uninterrupted repetition of a behavior beyond its usefulness. For example, picking at one's skin repetitively in the absence of itching.
The most common type of perseveration in FASD-affected persons is "stuck-in-set" perseveration, although they may also display continuous perseveration, especially when they are bored or anxious, Common examples of "stuck-in-set" perseveration in FASD-affected individuals include situations in which the individual "gets stuck":
- Making transitions during the school or work day (e.g., from lunch or gym, back to classroom work),
- Tolerating changes in schedules or everyday routines (e.g., when the work schedule or the bus route changes)
- Adjusting to changes in staff at school or work
- Ending an intense emotional feeling, especially feelings of anger, disappointment, sadness, etc.
- Changing topics of conversation
- Complying with requests to stop a favored activity.
For parents, teachers, and other caregivers of a person with FASD, one of the most frustrating parts of dealing with the person's "sticky" thoughts, attitudes, or behaviors is that he or she often gets upset when asked to give up the perseverative activity, topic, strategy, or emotion. And then he or she gets "stuck" in that emotion.
Perseveration in FASD-affected persons is often associated with other neurological impairments caused by prenatal alcohol exposure, including:
- Poor impulse control
- Poor self-monitoring
- Difficulty understanding or responding to feedback
- General inflexibility in thinking and acting
Sometimes, perseveration may be a response to anxiety. It may also be associated with memory impairments.
In some cases, stuck-in-set perseveration is an indirect rather than a direct result of neurological impairment. That is, when the person's other cognitive or academic impairments make performing tasks difficult, his anxiety about these tasks may lead him to "stick" to more comfortable tasks.
Understanding perseveration in an individual with FASD is critical. Without it, caregivers and other people who interact with the individual become frustrated and impatient with the individual when he does not let go of topics, emotions or behaviors. It is easy for a parent to see their FASD-affected child's "stubborn" behavior as willful; however, the effect of prenatal alcohol damage on the brain makes it very hard for the child to control his perseveration.
Medications are occasionally used for persons with FASD who have problems with perseveration; especially if the individual's perseveration is caused in part by anxiety. In some cases, the focusing or calming effect of the medication increases the likelihood that the person will respond better to environmental and behavioral interventions used at home, school, work, etc.
Cues, prompts, and other supports for helping a person with FASD can help to prevent, redirect, and reduce perseveration. However, not all individuals respond to the same types of environmental supports of accommodations. In addition, some FASD-affected individuals have great difficulty controlling perseveration; they may not be able to control it on their own, or in all circumstances.
If there are specific topics or activities that predictably evoke the student’s to perseverate (e.g., playing specific video games), then avoiding them, if possible, may work best. However, this is difficult in the "outside world", when shifts from a desirable activity (e.g., recess, lunch, etc.) to less desirable activities are required and usually inevitable.
Redirection is the most common environmental strategy used in managing perseveration. Depending on the situation and the individual, the following strategies may help the person to get "un-stuck":
- Changing the subject of conversation
- Starting a new activity
- Moving to a different place
- Placing an object (e.g., a key) in the student’s hand as a cue to move on.
However, adults should be careful when using highly desirable activities as the key to redirection (e.g., redirecting the child from a staying stuck on a topic of conversation by allowing him to play a desirable video game). The individual may then learn to use perseveration as a way to get the more desirable activity. If parents know this is a problem, it may help to brainstorm with their FASD-affected child ways to redirect him or her activities that are really useful.
Setting limits (e.g., a time limit or a number of times something is allowed) on a "sticky" favorite activity (such as watching TV or using the Internet) only works if the individual with FASD has the self-regulatory ability to understand and accept the limit.
Sometimes, parents or teachers may use the favored activity in which the FASD-affected person gets stuck to teach him or her relevant concepts or behaviors. For example, if the individual perseverates on puzzles, the teacher may use this as a way to encourage the student to learn number concepts, color concepts, or problem-solving strategies while engaged in the puzzle.
Should parents ignore some perseverative behavior?
When parents believe that their child's "sticky" behavior is motivated in part by a desire to gain attention or other positive response from adults or peers (refusing to go to bed, for instance), simply ignoring the behavior may be the best option.
However, ignoring the perseveration will not help if it has a neurological rather than a “behavioral” basis, as with many such behaviors in persons with FASD. In fact, ignoring perseveration often increases the problem.
If the individual uses perseveration on a desirable activity to avoid moving on to a difficult task, it may help to teach him or her specific ways to ask for help or a break before beginning the more difficult task. Extensive modeling of the alternative behavior, and lots of practice, are critical for this approach to help an FASD-affected person to stop perseverating. For some FASD-affected persons, it helps to record a video in which the individual models for herself performing one or more of the strategies that work for her to interrupt her stuck-in behavior.
Some individuals benefit from a specific routine that they and the adult-in-charge then use as a mantra as approach the transition from one activity to another. For example, they may use an alarm, sing a specific song, etc.
When perseveration is related to anxiety, some older children, teens or adults with FASD can be taught ways to reassure themselves in order to avoid getting stuck on the anxiety-producing topic. For example, if perseveration is triggered by anxiety-provoking concerns about an upcoming event, such as a test at school or a change in a work schedule, the individual may be able to use a memorized "script" to talk themselves out of perseverating. For instance: “I know that I can talk to my teacher / boss about this. It will be OK; I have a plan. I can move on.” Or, a self-talk script might be a way to ask for help, such as memorizing and then using a script such as, “I’m stuck; I need help moving on” so that someone else can help them to get un-stuck.