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THE TRUTH AND CONSEQUENCES OF FETAL ALCOHOL SPECTRUM DISORDERS

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Title: THE TRUTH AND CONSEQUENCES OF FETAL ALCOHOL SPECTRUM DISORDERS


1
THE TRUTH AND CONSEQUENCES OFFETAL ALCOHOL
SPECTRUM DISORDERS
  • Deborah E. Cohen, Ph.D.
  • Director, Office for Prevention of Mental
    Retardation
  • and Developmental Disabilities

2
Fetal Alcohol Spectrum Disorders
  • Appreciation is extended to Edward Riley, Ph.D.,
    University of California, San Diego, and Chair,
    National Task Force on Fetal Alcohol Syndrome,
    for making his slides available to me.

3
Fetal Alcohol Syndrome
  • Specific pattern of facial features
  • Pre- and/or postnatal growth deficiency
  • Evidence of central nervous system dysfunction

Jones, et al, 1973 Jones Smith, 1973 Lemoine
et al., 1968 photo Streissguth, 1997
4
Streissguth, 1994
5
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6
Differential Diagnosis of Physical Features Found
in Fetal Alcohol Syndrome
7
Differential Diagnosis of Physical Features Found
in Fetal Alcohol Syndrome (cont)
8
Differential Diagnosis of CNS and Behavioral
Feature Found in Fetal Alcohol Syndrome
9
Whats Drinking?A mere pause from thinking.
Byron, 1824
10
Risk Factors
  • Dose of alcohol
  • Pattern of exposure - binge vs chronic
  • Developmental timing of exposure
  • Genetic variation
  • Maternal characteristics
  • Synergistic reactions with other drugs
  • Interaction with nutritional variables

11
Historical views of alcohol as a teratogen
  • Foolish, drunken, or harebrain women most often
    bring forth children like unto themselves
    Aristotle in
    Problemata
  • Behold, thou shalt conceive and bear a son And
    now, drink no wine or strong drink.
  • Judges 137

Rosett, 1984
12
Contemporary HX of FASD
  • In 1973, Ken Jones and David Smith described the
    cluster of effects and coined the term, Fetal
    Alcohol Syndrome.
  • In 1989, Congress passed legislation requiring
    warning labels to be put on bottles.
  • In 1998, Congress passed the Fetal Alcohol
    Syndrome Prevention Act and established the
    National Task Force.
  • In 2004, CDC, NIAAA SAMHSA reached consensus on
    the use of FASD.

13
Medical Indicators of Alcohol/Drug Dependence in
Pregnant Women
  • Eclampsia
  • Spontaneous Abortion
  • Poor Nutrition
  • Liver Damage
  • Abruptio Placentae
  • Intrauterine Growth Retardation
  • Breech Presentation
  • Preterm Labor

14
Social and Medical Impacts
  • Poor Neonatal Outcomes, including the risk of
    preterm labor, FASD, stillbirth, mental
    retardation, hyperactivity, growth retardation,
    Sudden Infant Death Syndrome (SIDS), and
    permanent developmental problems
  • Poor Maternal Outcomes, including pre-term labor,
    abruptions, spontaneous abortions, STDs, HIV/AIDs

15
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16
Live Births in New Jersey 1997-2001
  • According to several studies it is estimated that
    between 5.8 and 11 of pregnant women use drugs
    and/or alcohol during their pregnancy.
  • National Estimates of Substance Use During
    Pregnancy.
  • 5 of 115,000 11 of 115,000
  • 5,750 12,650
  • According to the Electronic Birth
    Certificate.
  • Drinking 1.30 Drug Use 1.70
  • 1,495 1,950

17
Incidence of FAS (rates per 1000)
  • Seattle 2.8
  • Cleveland 4.6
  • Roubaix 1.3-4.8
  • Seattle
  • (FAS and ARND) 9.1
  • South Africa (Wellington) 78
  • Alaska 0.2 non AI/AN
  • 3 AI/AN
  • Aberdeen 2.7 AI/AN
  • BDMP 0.7
  • Atlanta 0.1
  • 0.3 full partial
  • IOM 0.6-3 IOM 2 - 8.5
    AI/AN

18
FAS Only the tip of the iceberg
  • Fetal alcohol syndrome
  • Fetal Alcohol Spectrum Disorders - FAE, ARND
  • Clinical suspect but appear normal
  • Normal, but never reach their potential

19
Prenatal exposure to alcohol, at least in high
doses, can cause permanent changes in the brain
  • These changes in brain may cause or contribute to
    many of the behavioral problems seen in
    individuals exposed to alcohol.
  • These changes in brain are not due to poor
    postnatal environments, being in foster care, or
    a host of other possibilities.
  • Knowing what brain areas are involved might
    enable us to develop better treatment strategies.

20
Brain damage resulting from prenatal alcohol
photo Clarren, 1986
21
Brain Regions Affected by Alcohol
22
Possible mechanisms for alcohols effects
  • Impaired progression through cell cycle
  • Impaired glia development - migration,
    neurotropic factor production, myelination
  • Impaired cell adhesion
  • Alterations in cell membranes
  • Altered production of or responsiveness to factor
    that regulate growth, cell division, or cell
    survival
  • Altered regulation of intracellular calcium
  • Increased production of free radicals

23
EFFECTS ON FOURCELLULAR PROCESSES
  • 1. CELL PROLIFERATION
  • 2. CELL MIGRATION
  • 3. CELL DIFFERENTIATION
  • 4. CELL TERMINATION

24
Facial features of FAS in the mouse
Adapted from Sulik Johnston, 1982
25
Stages of Embryogenesis
Cell Differentiation
Cell Proliferation
Cell Migration
Gastrulation
Continued Growth

Degree of Sensitivity
Implantation
Functional Maturation
Fertilization
Histogenesis
Birth
Organogenesis
0 10 20 30 40 50 60
70 80 90 280
Days
Embryonic Period
Fetal Period
26
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27
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28
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29
Subcortical Structures
Caudate
Lenticular
Thalamus



PEA
FAS



p

lt
0.001


p
lt 0.010


p
lt 0.050
30
Cranial Vault
31
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32
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33
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34
Growing up with FAS
Courtesy of Ann Streissguth
35
General Intellectual Performance

NC
PEA




FAS


Standard score
FSIQ
VIQ
PIQ
IQ scale
Mattson, S.N., 1997.
36
Executive Functioning Deficits
Move only one piece at a time using one hand and
never place a big piece on top of a little piece
1
3
2
Starting position
Ending position
Mattson, et al., 1999
37
Neuropsychological Performance
Mattson, et al., 1998
38
Secondary Disabilities
  • Individuals with FAS/FAE have a range of
    secondary
  • disabilities disabilities that the individual
    is not born with, and which could be ameliorated
    with appropriate interventions.

Streissguth, et al., 1996
39
  • Cognitive/Intellectual functioning
  • Activity and Attention
  • Learning and memory
  • Language and communication
  • Motor abilities
  • Spatial and processing abilities
  • Other neuropsych/executive functioning
  • Sensory motor Integration
  • Social skills and adaptive
  • Mental Health

40
Clinical Implications of Impairments for
Individuals with FASD
  • Poor judgment and decision making, which
    increases susceptibility to being victimized
    Innocent Delinquents
  • Attention deficits, which increase
    distractibility and lack of focus
  • Arithmetic disability, which leads to difficulty
    in handling money
  • Memory impairment, which makes learning from
    experience difficult

41
Clinical Issues Cont.
  • Difficulty abstracting, which makes it difficult
    to understand the consequences of ones behavior
  • Disorientations of time and space, which
    complicate accurately perceiving social cues,
    missing appointments
  • Impulsivity and poor self-regulation, which
    decreases tolerance for frustration, and makes
    them quick to anger

42
Clinical Implications of Impairments for
Individuals with FASD
  • Poor judgment and decision making, which
    increases susceptibility to being victimized
    Innocent Delinquents
  • Attention deficits, which increase
    distractibility and lack of focus
  • Arithmetic disability, which leads to difficulty
    in handling money
  • Memory impairment, which makes learning from
    experience difficult

43
Clinical Issues Cont.
  • Poor habituation which results in drowning in
    stimulation, emotional overload, shutting down
    and behaving irrationally
  • Perseveration which leads to doing the same thing
    over and over again
  • Poor judgment which leads to trusting anybody and
    behaving irrationally
  • Difficulty with self reflection which leads to
    not being able to express ones needs and not
    getting help

44
Reconceptualizing the Behavior of Persons with
FASD
  • It may be helpful for professionals, family
    members, and caretakers to reconceptualize how
    they view the behavior of a child with FAS/ARND
  • From seeing a child as ? To understanding a
    child as
  • Wont Cant
  • Bad Frustrated, defensive, challenged
  • Lazy Tries hard
  • Lies Fills in

45
Reconceptualizing the Behavior of the Person with
FASD
  • Doesnt try Exhausted or cant start
  • Mean Defensive, hurt, abused
  • Doesnt care Cant show feelings
  • Refuses to sit still Over-stimulated
  • Fussy, demanding Oversensitive
  • Resisting Doesnt get it
  • Attention getting Needs contact, support

46
Common Positive Characteristics of Persons with
FASD
  • Cuddly, cheerful, tactile, friendly and happy
  • Caring, kind, loyal, nurturing and compassionate
  • Trusting, loving, determined, committed and
    persistent
  • Curious, involved, fair and cooperative
  • Energetic, hard working and athletic
  • Artistic, musical and creatively intelligent
  • Kind with younger children and animals.

47
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48
For More Information Aboutthe Office for
Prevention and FASD
  • Visit
  • http//www.state.nj.us/humanservices/ofp.html
  • http//www.beintheknownj.org and
  • http//www.beintheknownj.net
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