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Fetal Alcohol Spectrum Disorder

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Title: BACKGROUND Author: Mount Sinai Hospital Last modified by: Diana Fox Created Date: 4/24/2001 11:48:29 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Fetal Alcohol Spectrum Disorder


1
Fetal Alcohol Spectrum Disorder
  • Dr. Brenda Stade, Mary Cunningham,
  • Doug Nugent St. Michaels Hospital

2
Outline
  • Introduction
  • Early Identification and Assessment
  • Diagnostic guidelines and assessment
  • Screening
  • Rational for early diagnosis
  • Cognitive, Behavioral, Social Development and
    Nutrition of Children, Birth to Age 6 years
  • Issues and Strategies
  • Focus on Families

3
Introduction
  • In Canada the incidence of Fetal Alcohol Spectrum
    Disorder (FASD) has been estimated to be 1 in 100
    live births.

4
Introduction
  • Caused by prenatal exposure to alcohol.
  • FASD is the leading cause of developmental and
    cognitive disabilities among Canadian children.

5
Introduction Fetal Alcohol Spectrum Disorder
Defined
  • Growth Restriction
  • Facial Anomalies
  • CNS Dysfunction
  • Prenatal Alcohol Exposure

6
Introduction
  • Cost of FASD annually to Canada of those 1 to 21
    years old, was 344,208,000 (95 CI 311,664,000
    376,752,000).
  • (Stade, 2004).

7
Introduction Etiology
  • Alcohol readily crosses the placenta and results
    in similar levels in the mother and fetus.
  • Rate of elimination is slower in the fetus.
  • Most teratogenic effect during organogenesis and
    development of the nervous system.

8
Etiology
  • When neuronal activity is abnormally suppressed
    during the developmental period, the timing and
    sequence of synaptic connections is disrupted,
    and this causes nerve cells to receive an
    internal signal to commit suicide, a form of cell
    death known as "apoptosis".
  • Addiction Biology 2004 Jun9(2)137-49.

9
Etiology
  • Teratogenesis is grossly dose related, although
    the threshold dose is still unknown and related
    to maternal/fetal susceptibility.
  • Risk to fetus greatest with more than 7 standard
    drinks per week (1 standard drink 13.6 grams of
    absolute alcohol).
  • Binge drinking of more than 5 ounces (142 grams)
    per occasion vs. 4 or more drinks per occasion.

10
Standard drinks 0.5 oz alcohol
12 oz (341 mL) can of beer (5 alcohol) 12 oz
(341 mL) bottle of cooler (5 alcohol) 5 oz (142
mL) glass of wine (12 alcohol) 1.5 oz (43 mL)
distilled spirits (40 alcohol) 3 oz (85 mL)
fortified wine e.g. sherry or port (18
alcohol )
11
Etiology
  • No safe time to drink during pregnancy.
  • No known safe amount.

12
Risk Factors
  • Maternal Age and Parity
  • Chronicity of Alcoholism
  • Socioeconomic Status
  • Polydrug Use
  • Ethnicity
  • Fetal Susceptibility.

13
Diagnostic Guidelines
14
Important Features of Diagnostic Guidelines
  • Minimize false negatives and false positives
  • Precisely define diagnostic criteria
  • Consider genetic and family histories
  • Multidisciplinary approach.

15
Rational for Early Diagnosis
  • Accurate and timely diagnosis is essential
  • to improve outcomes
  • decrease risk of secondary disabilities
  • increase opportunities for prevention
  • ensure more accurate estimates of incidence and
    prevalence.

16
Canadian Guidelines for Diagnosis CMAJ, March 2005
  • The Diagnostic Process
  • Screening and referral
  • Physical exam and differential diagnosis
  • Neurobehavioural assessment
  • Treatment and follow-up
  • Team members
  • Program director/Co-ordinator
  • Physician (trained in diagnosis)
  • Psychologist
  • Social worker
  • OT, Speech, psychiatrist, geneticist, addiction
    worker, community support workers, teachers etc.

17
Canadian Guidelines for Diagnosis
  • Physical Exam
  • General physical to rule out other disorders
  • Growth (at or below 10th percentile)
  • Facial features.

18
Growth Restriction
  • Growth restriction is demonstrated by height and
    weight at or below the tenth (10th) percentile.
  • Growth restriction may be apparent prenatally
    and/or postnatally.

19
Diagnosis Growth Restriction
20
Facial Features
  • Short palpebral fissures
  • Smooth or flat philtrum
  • Thin upper lip.

21
Facial Features
22
Facial Features
23
Associated Anomalies
  • Cardiac anomalies
  • Joint and limb anomalies
  • Neurotubal defects
  • Anomalies of the urogenital system
  • Hearing disorders
  • Visual problems
  • Severe dental malocclusions.

24
Canadian Guidelines for Diagnosis -Neuro-behaviour
al Assessment
  • Domains to be assessed by psychologist or team
  • Hard and soft neurological signs
  • Brain structure
  • Cognition (IQ)
  • Communication
  • Academic achievement
  • Memory
  • Executive functioning
  • Attention deficit/hyperactivity
  • Adaptive behaviour, social skills, social
    communication.

25
Early Infancy
  • Tremors
  • Poor suck
  • Hypotonic/Hypertonic
  • Irritability
  • Feeding problems
  • Developmental delay.

26
Early Childhood
  • Cognitive Problems
  • Motor Issues
  • Behavioral Presentation
  • Sensory Dysfunction
  • Speech Delay
  • Hyperactivity
  • Socialization Difficulties.

27
Canadian Guidelines for Diagnosis Maternal
Alcohol History in Pregnancy
  • Key to establishing an accurate diagnosis
  • Require confirmation based on clinical records,
    self-report, reliable observation.

28
Classification of FASD
  • Fetal Alcohol Syndrome (FAS)
  • Partial Fetal Alcohol Syndrome (PFAS) with
    confirmed maternal alcohol exposure
  • Alcohol-Related Neuro-Developmental Disorder
    (ARND) with confirmed maternal alcohol exposure.

29
Diagnostic Criteria
  • FAS
  • Evidence of growth impairment
  • 3 facial anomalies
  • 3 central nervous system domains impaired
  • Confirmed or unconfirmed alcohol exposure.

30
Diagnostic Criteria
  • Partial FAS
  • 2 facial anomalies
  • 3 central nervous system domains impaired
  • Confirmed alcohol exposure.

31
Diagnostic Criteria
  • ARND
  • 3 central nervous system domains impaired
  • Confirmed alcohol exposure.

32
Screening
33
Screening and Primary Care Referral
  • Referral of individuals to FASD diagnostic
    clinics
  • Evidence of prenatal exposure to alcohol (or
    probable) with suspected or confirmed CNS
    dysfunction or
  • Presence of 3 characteristic facial features with
    growth deficits with or without known prenatal
    alcohol exposure.

34
Conclusion
  • Diagnosis requires a multi-disciplinary approach
  • Diagnosis is complex and guidelines are well
    defined and cannot be a gestalt approach
  • Confirmed prenatal alcohol exposure is required
    for a diagnosis of Partial FAS and ARND
  • Screening does not equate to diagnosis.

35
Cognitive, Behavioral, Social Development and
Nutrition of Children from Birth to Age 6
36
Cognitive
37
Cognition
  • Attention problems and memory deficits often make
    learning difficult in the young child.

38
Cognition
  • Infants and young children with FASD live with
    differing levels of cognitive abilities
  • All programs to develop cognitive abilities
    should be child specific.

39
Cognition
  • How does the individual child with FASD
  • learn?
  • Some are primarily visual learners, some are
    tactile learners, some kinesthetic, and some
    learn best by listening.
  • (Mountford,A. The Golden Hoop of Life).

40
Cognition Strategies
  • If a child learns best through music
  • If a child learns through body movement
  • If a child learns best through listening
  • If a child is a tactile learner
  • (Mountford, A. The Golden Hoop of Life).

41
Cognition Strategies
  • May need to use short sentences
  • Break down information and instruction
  • Repetition, Repetition, Repetition
  • Teach one concept at a time.

42
Cognition Strategies
  • It took him four weeks at age four to learn the
    colour red. We decided in February he was going
    to learn his colours. So everyday of the month I
    dressed him in red.
  • The teacher had to say X youre wearing a red
    shirt today. Show me your shirt. Its red. X
    youre wearing red pants today. Something had to
    be red.

43
Cognition Strategies
  • Treasure hunts
  • Problem-solving activities
  • Visual-spatial games
  • Story building
  • Math skills visual teaching.

44
Cognition
  • Impacting on the development of cognitive
    skills is the childs ability to process his
    sensory world.

45
Sensitivity
46
Sensory Processing
  • Many infants and young children
  • with FASD have difficulty processing and
    organizing sensory information they receive from
    their own bodies and the outside world.

47
Sensory Processing
  • Sensory processing is a developmental process
  • Takes place in the central nervous system
  • Involves ability to take in information
  • through the senses, organize it in our brains
    and use it to respond appropriately.

48
Sensory Processing
  • The brain must properly process information from
    the senses to develop
  • concentration
  • organization
  • learning ability
  • specialization of each side of the body and brain
  • self-esteem
  • self-control.

49
Sensory Processing
  • How does sensory processing abilities impact on
    day-to-day life of a child with FASD?

50
Normal Sensory Integration
  • Schwab, D. (2001).

51
Sensory Processing Dysfunction
52
Sensory Processing
  • Hypersensitive
  • Touch (Touch Processing)
  • Noise (Auditory Processing
  • Visual Input (Visual Processing).
  • Dysfunction in Behavioural Outcomes of Sensory
    Processing.

53
Sensory Processing Strategies
  • Place your child first or last in line
  • Wash clothes a couple of times before wearing
  • Use soft bedding
  • Remove tags from clothes
  • Avoid
  • ties under the chin
  • thick seams in clothing
  • clothes that are scratchy
  • Avoid tickling.

54
Sensory Processing Strategies
  • Weighted Vests
  • Deep Massage
  • Bear Hugs
  • Activities using a number of muscles groups.

55
Sensory Processing Strategies
  • Tone down the rooms effects on all senses
  • Avoid decorated rooms
  • Walls should be single colour and very pale
  • Avoid clutter.

56
Sensory Processing Strategies
  • Provide a place/space where the child can have a
    quiet place to be
  • Avoid crowds and places with many people, lots of
    noise and high activity level
  • At daycare, preschool, and school group activity
    should avoid large groups.

57
Sensory Processing Strategies
  • Group play use little mats
  • Recognize why a child may refuse to participate
    in a game
  • Occupational Therapy.

58
Sensory Processing
  • Hyposensitive
  • Pain
  • Hot or Cold

59
Strategies Hyposensitive
  • Supervision
  • Avoid overdressing in summer
  • Ensure dressed adequately in winter
  • Ensure child monitored and receives adequate care
    when ill.

60
Behaviours
  • Behavioural and Emotional Responses may reflect
    the childs outcomes of sensory processing.

61
Behaviour Hyperactivity
  • Due to the childs sensory processing
    difficulties he or she may have a constant need
    for activity.

62
Strategies
  • Fidget Items
  • Short periods of sitting still
  • Hammock
  • Teaching during activity
  • Music.

63
Difficult Behaviours
  • What is needed is a change in thinking from
    discipline to redirection or re-teaching
  • Prevention sensory strategies,
    transitioning.

64
Strategies
  • Be firm but supportive
  • Choose one or two critical behaviors at a time to
    work on
  • Ignore minor negative behaviour
  • Keep the mood positive. Give five times
  • more praise to every one correction.
  • Identify warning signs re melt down
  • Teach child to self-monitor.

65
Difficult Behaviours
  • Calming strategies
  • Comfort corner
  • Tents and caves
  • Very short time outs
  • Deep pressure.

66
Crying Infancy
  • Crying is an infants way of expressing his/her
    needs.
  • Infants prenatally exposed to alcohol may seem
    like they are crying constantly.

67
Crying Infancy
  • Avoid, if you can, letting a baby get to a state
    of frantic crying.
  • Get to know strategies that work best, and tell
    other caregivers how the baby likes to be handled.

68
Crying Infancy
  • Wrap the infant snugly in a receiving blanket
    when not sleeping
  • Use a soother
  • Bathing may settle some, quiet music may help
    others
  • Rocking the infant up and down rather than back
    and forth has been found to be soothing for some
    infants.

69
Crying Young Child
  • Crying is a method of communication for all young
    children
  • In the child with FASD be alert for
  • sensory overload
  • inability to communicate
  • mood problems.

70
Crying Young Child
  • Modify environment
  • Ensure child can communicate needs pictures,
    sign language
  • Assessment by a mental health professional.

71
Health Illness
72
Health and Illness
  • Generally, FASD is not defined by associated
    physical disability or illness.

73
Health Illness
  • Some children with FASD are born with organ
    anomalies.

74
Organ Anomalies
  • Cardiac anomalies
  • Joint and limb anomalies
  • Neurotubal defects
  • Anomalies of the urogenital system.
  • Hearing disorders
  • Visual problems
  • Severe dental malocclusions.

75
Health Illness
  • Zhang and others (2005) demonstrate the adverse
    effects of alcohol on immune competence and the
    increased vulnerability of ethanol-exposed
    offspring.

76
Health Illness
  • The infant should not be exposed to environmental
    irritants such as tobacco smoke
  • Protect the infant from exposure to viruses.

77
Health Illness
  • Young children with FASD are particularly prone
    to upper respiratory illnesses and ear infections
  • Monitoring and ensure treatment as necessary.

78
Health Illness
  • Motor deficits are not uncommon in infants and
    young children with FASD.
  • Infant Pre-school stimulation programs
  • Occupational Therapy.

79
Sleep
80
Sleep Disturbances
  • Sleep disturbances among individuals with FASD
    are not uncommon.
  • Younger children often have trouble falling
    asleep and waking.

81
Sleep Disturbances
  • They may have trouble settling and wake often
    throughout the night.
  • Night terrors among individuals with FASD can
    continue throughout life.

82
Sleep Strategies
  • Establish rituals for saying good night
  • Start a calming bedtime routine an hour before
    bedtime
  • A light snack before bed may be beneficial for
    some children.

83
Sleep Strategies
  • Decrease sensory stimulation in the bedroom
  • White noise when the child is in bed may be
    calming to some but distracting to others
  • Night-lights help some young children but for
    some can lead to night terrors.

84
Sleep Strategies
  • Start young to promote the child sleeping in his
    or her own bed
  • Melatonin may be beneficial
  • Childproof the house for night wanderers
  • As much as possible wake the child in the same
    predictable way every morning.

85
Nutrition
86
Growth and FAS
  • Substantial literature on the association between
    maternal alcohol consumption during pregnancy and
    decreased neonatal weight, length and head
    circumference.
  • Unsure of the effect of alcohol on growth
    parameters later on in life.
  • McFadyen, K. (2005)

87
Studies Growth and FASD
  • Russell (1991)
  • Differences in head circumference and ht at 6
    years
  • Sampson (1994)
  • No detectable differences from 8 mos to 14 years
  • Day (2002)
  • 1st trimester exposure predicted significant
    reductions in wt, HC, and length
  • 2nd trimester exposure predicted significant
    reductions in wt and skinfold thickness.

88
Nutrition and FASD
  • Infants and young children with FASD must have
    there growth followed regularly
  • Those with poor growth/growth restriction should
    be followed by a dietician
  • Motor dysfunction resulting in poor suck and
    swallow requires OT intervention
  • Picky eaters requires patience, persistence,
    and imagination.

89
Essential Fatty Acids
90
What we know.
  • Essential fatty acids (EFA) are necessary for the
    formation of healthy cell membranes, proper
    development and function of the brain and nervous
    system -
  • Omega 3 and Omega 6 fatty acids must be provided
    from food as they cannot be synthesized by the
    body.
  • McFadyen, K. (2005)

91
ESSENTIAL FATTY ACIDS
OMEGA 3 FATTY ACIDS
OMEGA 6 FATTY ACIDS
Green leafy vegetables, flax, flaxseed oil,
canola oil, walnuts, Brazil nuts, fish oil, fish,
tofu, and eggs
Vegetable oils (soybean, safflower, and corn
oil), nuts and seeds
92
What we know continued
  • Some evidence indicates that
  • fatty acid deficiencies or imbalances may
    contribute to the negative sequelae of some
    childhood
  • neuro-developmental disorders.
  • McFadyen, K. (2005)

93
EFA Supplementation
  • There have been no studies to date looking at EFA
    supplementation and children with FASD.
  • Some studies have demonstrated the benefits of
    EFA in children with other neuro-developmental
    disorders but other research have found no
    effect.

94
Thoughts..
  • Pregnancy stresses maternal EFA status because
    the mother must supply fatty acids needed for
    fetal and placental growth.
  • Alcohol can disturb placental transport.
  • Alcohol increases fatty acid catabolism
    resulting in ???

95
What we do not know.
  1. Whether supplementation of essential fatty acids
    may benefit in children with FASD
  2. Optimal dosage of fatty acids
  3. Optimal composition (Omega 3 and Omega 6 fatty
    acids)
  4. Dose response relationship
  5. Duration or treatment.

96
In the End
  • Encourage the young child with FASD to eat a
    variety of foods from the four food groups.
  • To increase intake of EFAs offer fish, eggs,
    nuts, seeds and use vegetable oils.
  • Monitor growth.
  • McFadyen, K. (2005)

97
Social Skills Friendships
98
Social Skills and Friendships
  • Social skill development should begin early for
    children with FASD.
  • Distractibility, aggressiveness and, and
    impulsivity can interfere with social
    development.

99
Social Skills and Friendships
  • Social skills program
  • Practice, model, rehearse social skills.
  • Foster activities that the child likes and is
    good at
  • Brief activities in small groups.

100
Social Skills and Friendships
  • Invite other children to the home and adapt the
    situation so it is fun for the other children
  • Educate young children that they may learn or
    respond to situations or stimuli somewhat
    differently than others.

101
Caregivers
102
Strategies for Caregivers
  • Keep remembering they are not willfully trying to
    make you exhausted or crazy
  • Forgive yourself when you lose your temper
  • Allow yourself to grieve
  • Advocate for their needs
  • It will make you feel better about them and
    yourself.

103
Strategies for Caregivers
  • Do something for yourself every day
  • Find someone you can talk to
  • Try to get in as many breaks as possible
    friends, family, respite
  • Monitor yourself for signs of increased stress
    and depression.

104
Thank-You
  • Thank-you for listening!

105
(No Transcript)
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