The Behavioural Phenotype of Fetal Alcohol Spectrum Disorder

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The Behavioural Phenotype of Fetal Alcohol
Spectrum Disorder

• The births of all things are weak and tender,
  and therefore, our eyes should be intent on
  beginnings." -Michel Eyquem Montaigne
• Inaugural Ivey Symposium
• June 6, 2006

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What is Fetal Alcohol Spectrum Disorder (FASD)?

• FASD is a neurodevelopmental disorder caused by
  exposure to alcohol in utero
• Has effects on both brain and behaviour

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Diagnostic Criteria

• Pre and postnatal growth retardation
• CNS damage
• Characteristic facial dysmorphology

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• Only a minority of children meet criteria for the
  full blown syndrome
• How do we diagnose without visible signs?

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The Motherisk Follow-up Clinic

• Began in 1996
• Provides a specialized diagnosis in a
  central location
• Many obstacles exist
• Not every child has physical symptoms
• ADHD with comorbid FASD 70 of children
  with FASD are diagnosed with ADHD
• Long wait lists

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The Issue of ADHD

• Children with FASD present with a unique and
  specific behavioural profile compared to children
  with ADHD (Greenbaum (2004) Fantus et al.,
  (2004))

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The Issue of Access

• The majority of children with FASD reside in
  communities with limited access to a specialized
  diagnosis
• How do we address this issue?

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Aims of the current research

• To identify whether the diagnosis of FASD can be
  predicted by individual items from a validated
  questionnaire
• To compare children with FASD to children with
  ADHD and controls on this questionnaire
• To develop an empirically derived screening tool
  (Streissguth, 1998)

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Methods

• Participants children between the ages of 6-16
  years.
• FASD (dx n30)
• ADHD (dx n30) No exposure history
• Controls (n 30) No exposure history, LD, ADHD
• Exposure History (FASD) Confirmed by
• Verbal report of biological parent or relative
• Knowledge that the child suffered alcohol
  withdrawal at birth
• The child having been place in care because of
  maternal alcohol abuse

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The Child Behaviour Checklist (CBCL Achenbach,
1991)

• 113 item parent questionnaire
• T-scores yield
• Competence Scales
• 3 Broadband scales
• 8 Narrowband scales
• DSM Oriented Scales

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Item selection

• Selected only 12 based on the work of Greenbaum
  (2000)

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CBCL 12 Items

• 1 acts too young for his/her age
• 3 argues
• 8 cant concentrate/poor attention
• 10 cant sit still/restless/hyperactive
• 16 cruelty/bullying/meanness to others
• 22 disobedient at home
• 26 no guilt after misbehaving
• 41 impulsive/acts without thinking
• 43 lying or cheating
• 74 showing off/clowning
• 81 steals from home
• 82 steals outside

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Analyses of Data

• Frequency Counts
• Proportions endorsed per group (chi square)
• Endorsement totals per item/group Discriminant
  Function Analysis (DFA)
• Sensitivity and Specificity Receiver Operating
  Curves (ROC)

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Receiver Operating Curves
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CBCL items involving significant group
differences(Controls FASD)
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Seven items most strongly differentiating FASD
from control

• 1 acts too young for his/her age
• 8 cant concentrate/poor attention
• 9 cant sit still/restless/hyperactive
• 22 disobedient at home
• 26 no guilt after misbehaving
• 41 impulsive/acts without thinking
• 43 lying or cheating

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ROC AnalysisFASD and Controls
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CBCL items involving significant group
differences(FASD and ADHD)
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Six items most strongly differentiating FASD from
ADHD

• 1 Acts too young for his/her age
• 16 cruelty/bullying/meanness to others
• 26 no guilt after misbehaving
• 43 lying or cheating
• 81 steals from home
• 82 steals outside

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ROC AnalysisFASD and ADHD
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Screening checklist for FASD

• Step 1 Identifying behaviour suggestive of FASD
• The following questions should be asked of the
  childs parent/guardian to determine whether the
  childs behaviour is suggestive of FASD

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Screening Checklist Continued

• Does your child act too young for his/her age?
• Does your child have difficulty concentrating and
  cant pay attention for long?
• Is your child disobedient at home?
• Does your child lie or cheat?
• Does your child lack guilt after misbehaving?
• Does your child act impulsively and without
  thinking?
• Does your child have difficulty sitting still/is
  restless/hyperactive?

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• If the parent answers YES to at least 6 out of 7
  items this is suggestive of FASD with comorbid
  ADHD
• If the child does NOT exhibit behaviour
  consistent with ADHD then they must receive a
  score of 3 out of 4 on the conduct related items

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Step 2 Differentiating FASD from ADHD

• i). The child needs to exhibit 2 of the following
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• Does your child lack guilt after misbehaving?
• Does your child act cruel, bully or is mean to
  others?
• Does your child act young for his/her age?

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Step 2Continued

• OR
• ii). 3 of the following 6
• Does your child lack guilt after misbehaving?
• Does you child act cruel, bully or is mean to
  others?
• Does your child act young for his/her age?
• Does your child steal from outside the home?
• Does your child steal from home?
• Does your child lie and cheat?

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Clinical Implications

• Address the issue of access
• Spare the long wait times for a diagnosis
• Misdiagnosis of ADHD as the primary diagnosis

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Limitations

• Dose and timing of alcohol exposure
• Confounders
• Small sample size
• Clinic referred

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Future Directions

• Compare to children diagnosed with conduct
  disorder
• Replicate and empirically validate
• Neuroimaging and mapping

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Acknowledgments

• Rovet Lab Meagan Williamson, Dina Lafoyannis,
  Sarah Borokowski, Erin Sheard, Dr. Mary Desrocher
• Canadian Institute of Health Research (CIHR)