Attachment Disordered Children with Fetal Alcohol and Drug Exposure

1
Attachment Disordered Children with Fetal Alcohol
and Drug Exposure

• Lois A. Pessolano Ehrmann PhD, LPC, CAC-
  Diplomate
• Registered ATTACh Therapist
• Carol McFall M.Ed. LPC, CAC
• Outpatient Therapist
• Counseling Alternatives Group
• 444 East College Avenue, Suite 460
• State College, PA 16801
• [phone]

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Spider Web Walking
3
Learning Objectives

• Review the neurological deficits or impairments
  in this population.
• Strategies to support and guide parents in
  understanding behaviors and issues.
• Treatment strategies specific to this population.

4
Overview of Presentation

• Introductory Remarks
• Definitions and concepts
• Current Models of FASDs.
• Incidences of FASDs in US foster and adopted
  children and in adopted children from foreign
  countries.
• Signs and Symptoms
• Visible versus invisible
• Attachment versus FASD versus Complex Trauma
• FASD versus true ADHD versus PTSD versus LDs
• Some Helpful Strategies, Tools and Resources

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What is FASD?

• Fetal Alcohol Spectrum Disorder refers to a
  constellation of physical and mental birth
  defects that may develop in individuals whose
  birth mothers consumed alcohol during pregnancy.
  (Duquette et al., 2006)
• Ethanol freely crosses the placenta, thus
  directly affecting developing fetal cells and
  tissues. (Niccols, 2007)
• Alcohol as are other drugs as well is a teratogen.

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History

• First reference to adverse effects of alcohol on
  the fetus
• Beware and drink no wine or strong drinkfor lo,
  you shall conceive and bear a son. (Judges 134,
  5)
• First scientific study
• Sullivan 1899 increased rate of still-birth and
  infant death in children of alcoholic women
• 1940s Haggard and Jellinek concluded that the
  developmental abnormalities of children born to
  alcoholic mothers were secondary to the
  environment in which they were raised.
• 1950s and 1960s French studies identified
  children of alcoholic mothers as having
  malformations, growth deficiency, and psychomotor
  disturbances (Lamache, 1967 Lemoine, Harousseau,
  Borteryu, Menuet, 1968 as cited in Niccols,
  2007). No one really paid too much attention.
• 1970s interest in the adverse effects of alcohol
  increased and concern about alcohol as a
  teratogen was mentioned. Streissguth, now an
  famous researcher in the field of FASDs started
  researching the patterns of malformation that
  occurred in children born to alcoholic mothers
  who drank while they were pregnant and the tern
  Fetal Alcohol Syndrome was coined.
• 1980s-the new millennium in 2008 there have been
  hundreds of investigations identifying the risks
  and consequences of consuming alcohol during
  pregnancy and these reports have been
  supplemented by animal experimental study as
  well. Streissguth (1997) in her book Fetal
  Alcohol Syndrome reports on her most
  comprehensive well know study.
• Lots of studies have looked at the
  characteristics of children prenatally exposed
  and new brain imaging technologies have really
  helped to link brain effects to behavioral
  expressions or manifestations.
• Very few studies on how to assist persons who
  have been exposed.

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Current Model and Conceptions of Fetal Alcohol
Spectrum Disorders

• From animal studies (rats)
• Investigations on children, adolescents and
  adults with known histories of maternal use
  during pregnancy including post-mortem
  evaluations
• In last 10 years greatly prolific due to new
  technologies in fMRIs, SPECT scans and other
  neuro-imaging procedures.

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FASDs

• 
  

PAE
FAS
PFAS
ARND
FAE
Death
ARBD
38 of all individuals who have a FASD have the
physical craniofacial features which means that
62 do not!
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Facial Anomalies
From Wattendorf et al., (2005)
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Examples of Variability
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The Faces of Persons who have Fetal Alcohol
Syndrome
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People who have FASD
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Diagnosis of Fetal Alcohol Spectrum Disorders

• Fetal Alcohol Syndrome
• (American Academy of Pediatrics,
  2000)
• Confirmed maternal alcohol consumption
• Growth deficiency
• Specific patterns of anomalies
• Central nervous system abnormalities
• FAS Diagnostic and Prevention Network (2004)
• 4 digit code of all FASDs

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Prevalence of FASD in the US Population
Statistics on FASD in US For full blown FAS CDC
0.2-1.5/1000 births Other Studies
suggest 0.5-2.0 per 1000 births For all
FASD Researches believe all FASDs are 4Xs the
prevalence of FAS. 10 per 1000 births or 1 of
the US population UDHHS (2007) 40,000 newborns
a year meet the criteria for a FASD. High Risk
US Populations Native Alaska 3.0-5.6 per 1000
births Native American 9-10 per 1000
births Source NIAAA May Gossage retrieved
2008
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Prevalence of Prenatal Drug Exposure

• Chasnoff (1989) 11 of all newborns,
  approximately 459,690 are exposed prenatally each
  year.
• Gomby Shiono (1991) 739, 000 women use illicit
  drugs during pregnancy every year.
• Schipper (1991) A substance exposed infant is
  born more frequently than once ever 90 seconds.

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FASD and Prenatal Drug Exposure Incidences in US
Foster/Adopted Children
About our Children Not much is known. Wedding
et al., (2007) psychologist did not have
accurate understanding about FASDs, danger of
alcohol use in pregnancy. Peadon et al., (2008)
Very few places do accurate diagnosis of FASDs
and most are located in North America. What is
follows Foster Children study in Washington
State. Astley, Stachowiak, Clarren, Clausen
(2002) FAS 10-15 times higher than in the
general population Mayet et al., (1983),
Streissguth et al., (1985) estimated that 73 to
80 of all children in US foster care or placed
for adoption have full blown FAS. Ehrmann (2006)
found that 28 of adopted children out of the US
foster care system were exposed to alcohol
prenatally and 47 were exposed to some illicit
drug prenatally.
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Adopted Children from Foreign Countries
Eastern Europe 15 per 1000 births Extrapolated
to approximately 21,000 children born with FASD
each year Source Orphan Doctor _at_
www.orphandoctor.com
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Risk Factors

• Dose of alcohol
• Pattern of exposure
• Binge versus chronic
• Developmental timing
• Of exposure
• Genetic variation
• Maternal characteristics
• Synergistic reactions with
• other drugs
• Interaction with nutritional
• variables

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Dosage Effect
Source Larry Burd, PhD North Dakota Fetal
Alcohol Syndrome Center 501 N. Columbia
Road Grand Forks, ND 58203
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Dosage Example
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Developmental Timing of Exposure
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The Rest of The StoryStreissguth and Colleagues

• Primary Disabilities
• Lower IQ
• Impaired ability in reading, spelling, and
  arithmetic
• Lower level of adaptive functioning more
  significantly impaired than IQ

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Typical Disabilities

• Typical Disabilities
• Sensory Integration Issues
• Are overly sensitive to sensory input
• Upset by bright lights or loud noises
• Annoyed by tags in shirts or seams in socks
• Bothered by certain textures of food
• Have problems sensing where their
  body is in space (i.e., clumsy)

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Typical Disabilities Continued

• Memory Problems
• Working memory
• Multiplication
• Time sequencing
• Information Processing Problems
• Do not complete tasks or chores and may appear to
  be oppositional
• Have trouble determining what to do in a given
  situation
• Do not ask questions because they want to fit in
• Say they understand when they do not
• Have verbal expressive skills that often exceed
  their level of understanding
• Misinterpret others words, actions, or body
  movements
• Have trouble following multiple directions

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Typical Disabilities Continued

• Executive Function Problems
• Go with strangers
• Repeatedly break the rules
• Do not learn from mistakes or natural
  consequences
• Frequently do not respond to point, level, or
  sticker systems
• Have trouble with time and money
• Give in to peer pressure
• Cannot entertain themselves
• Trouble shifting from task to task
• Attention issues
• Self-Esteem and Personal Issues
• Function unevenly in school, work, and
  development
• Experience multiple losses
• Are seen as lazy, uncooperative, and unmotivated
• Have hygiene problems
• Do not accurately pick up social cues

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Typical Disabilities Continued

• Hearing, speech and language
• Due to craniofacial abnormalities of FAS
• Cleft palate
• Otitis media with effusion and conductive hearing
  loss
• Voice dysfunction, articulation disorders
• Speech and language delays
• Language abilities seem lower than would be
  expected given child IQ

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Typical Disabilities Continued

• Social Development Issues
• Atypical attachment behavior and impairment in
  state regulation
• Outgoing, socially engaging, affectionate and
  excessively friendly
• Preschoolers tend not to appear to differentiate
  familiar from unfamiliar
• Studies citing parental and teacher reports
  indicate arrested social development rather than
  delayed social development
• Deficits in Theory of Mind (TOM)

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Secondary Disabilities

• Mental health issues
• Disrupted school experience
• Trouble with the law
• They lie (Rasmussen, Talwar, Loomes, Andrew
  (2008)
• Inappropriate sexual behavior
• Confinement in jail or treatment facilities
• Alcohol and drug problems
• Dependent living
• Employment problems

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Percentage of Persons with FAS or FAE that had
Secondary Disabilities
? Age 6 ? Age 12 ? Age 21
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FASDs and the Brain
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Alcohol Affects the Brain
Source Teaching Students with Fetal Alcohol
Spectrum Disorders Florida State University
Center for Prevention and Early
Intervention Policy (2005)
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Brain Structure and Function Studies

• Damage depends on the state of embryological
  development
• Conception to first weeks of prenatal
  development
• cytotoxic or mutagenic
• 4-10 weeks after conception
• Excessive cell death in the CNS and abnormal
  nerve cell migration
• Disorganization of tissue structure and
  microcephaly
• 8-10 weeks and on
• Disorganization and or delay in cell migration
  and development
• Third Trimester
• Damage to the cerebellum, hippocampus, and
  prefrontal cortex

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Continuum of Brain Dysfunction
Source Larry Burd, PhD North Dakota Fetal
Alcohol Syndrome Center 501 N. Columbia
Road Grand Forks, ND 58203
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Before Birth

• Low growth rate due to suppression of growth
  hormone in hypothalamus
• Increases HPA activity and disrupts hormonal
  interactions between maternal and fetal systems
  affecting the development of fetal metabolic,
  physiologic and endocrine functions
• Disrupts synaptogenesis causing neurons to commit
  suicide (die by apoptosis) on a massive scale

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Disrupted Synapsogenesis
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Early Development

• HPA disruptions result in high basal and post
  stress corticol levels
• Hyper-responsiveness to stress and immune system
  vulnerabilities
• High levels of irritability and feeding and
  sleeping problems
• As preschoolers short, skinny children with
  butterflylike movements who are hyperactive
  and/or excessively friendly and fearless
  (Streissguth Giunta, 1988).
• Developmental delays, language issues and poor
  motor coordination are also noted during this
  period of development

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Hippocampus in the Human Brain
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Hippocampus

• Plays a major role in
• Short term memory
• Spatial navigation
• In a MRI study Rijkonen, Salonen, Partanen,
  Verho (1999) found that children with FAS have
  smaller left hippocampus volume then right and
  this is associated with memory deficits.

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Hypothalamus in the Human Brain
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Hypothalamus

• The Hypothalamus does the following
• Hormone regulation and metabolic processes
• Linking of nervous system to the endocrine system
  via the pituitary gland
• Controls hunger, thirst, body temperature,
  fatigue, anger, circadian cycles and sexual drive
  and is part of fight/flight/freeze
• Suppression of growth hormone controlled by
  Hypothalamus happens in children with FASD.
• Dysregulation

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Basal Ganglia in the Human Brain
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Basal Ganglia

• A group of nuclei/interconnected in healthy
  individuals brains with the cerebral cortex,
  thalamus and brain stem.
• Responsible for
• Motor control
• Cognition
• Emotions
• Learning
• MRI studies show disproportionate reductions in
  basal ganglia volume in children with FAS and FAE
  especially in the caudate nucleus which is
  involved in higher cognitive functions and
  connected neuronally to the frontal lobes where
  executive functioning resides (Archibald et al.,
  2001).
• PET studies reveal reduced metabolic activity in
  the caudate nucleus in high functioning
  adolescents and adults with FAS (Clark et al.,
  2000).

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The Corpus Callosum
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Corpus Callosum

• What does it do?
• Connects the left and right hemispheres of the
  brain
• Consists of 200- 250 million contralateral axonal
  projections
• Inter-hemispheric communication
• Abnormalities in individuals with FAS including
  agenesis and thinning in the anterior and
  posterior regions.
• Displacement of the isthmus and splenium related
  to deficits in verbal learning.

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Corpus Callosum in the Human Brain
A. Magnetic resonance imaging showing the side
view of a 14-year-old control subject with a
normal corpus callosum B. 12-year-old with FAS
and a thin corpus callosum C. 14-year-old with
FAS and agenesis (absence due to abnormal
development) of the corpus callosum. Source
Mattson, S.N. Jernigan, T.L. and Riley, E.P.
1994. MRI and prenatal alcohol exposure Images
provide insight into FAS. Alcohol Health
Research World 18(1)4952.
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Alcohol Effects of Corpus Callosum
These two images are of the brain of a 9-year-old
girl with FAS. She has agenesis of the corpus
callosum, and the large dark area in the back of
her brain above the cerebellum is essentially
empty space. Source Mattson, S.N. Jernigan,
T.L. and Riley, E.P. 1994. MRI and prenatal
alcohol exposure Images provide insight into
FAS. Alcohol Health Research World 18(1)4952.

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Cerebellum in the Human Brain
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Cerebellum

• Responsible for
• Integration of neural pathways between cerebellum
  and cerebral motor cortex
• Motor skills
• Balance, coordination
• Learning in terms of attention and language and
  music processing
• Sensory perception/ proprioceptive feedback
• For individuals with FASDs
• Reductions in cerebellar volume specifically in
  the anterior vermis.
• Reductions are linked to dyslexia
• Jacobson et al., (2008)
• Eye blink conditioning is a cerebellular-mediated
  Pavlovian conditioning paradigm that involves
  contingent temporal pairing of conditioned
  stimulus (tone) with an unconditioned stimulus
  (brief air puff to the eye that elicits a
  reflexive blink). Children with FASD are impaired
  in this response indicating that the cerebellum
  and brain stem areas are highly affected by
  alcohol prenatally. This procedure could help in
  diagnosis and treatment intervention.

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Frontal Lobes
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Other Anomalies

• EEG readings (Kaneko et al., 1996)
• Atypical in approximately 50 of the children and
  adolescents with FASD
• Reductions in the power of the left H alpha
  frequencies suggesting less mature brain
  activity.
• Prolonged latency in P300 spikes in parietal
  cortex suggesting deficits in information
  processing.

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Other Anomalies Continued

• Too much grey matter
• Not enough white matter
• Similar metabolic activity in both hemispheres
  when it is supposed to be different
• Too much blood in the right frontal region which
  is characteristic of children with executive
  function problems

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Interventions What will Help?

• Lots of studies on characteristics and brain
  differences
• Not a lot of studies on intervention efficacy or
  outcome

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Premji et al., 2006

• Only three intervention studies out of ten had
  the rigor needed required to support efficacy.
• Conclusion There is limited scientific evidence
  upon which to draw recommendations regarding
  efficacious interventions for children and youth
  with a Fetal Alcohol Spectrum Disorder.
  Clinicians, researchers, service providers,
  educators, policy makers, affected children and
  youth and their families and others need to
  urgently collaborate to develop a comprehensive
  research agenda for this population.

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Common Co-occurring/Misdiagnoses of FASD

• ADD
• ADHD
• ODD
• RAD
• LD
• Speech and language delay
• PDD
• Developmental Receptive Language Disorder
• Sensory Integration Dysfunction
• Conduct Disorder, Seriously Emotionally Disturbed
• Borderline Personality Disorder
• Antisocial Personality Disorder
• Autism, Aspergers

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Misdiagnosis

• ADHD
• Hausknecht et al., (2006)
• Rats exposed prenatally to alcohol have attention
  deficits similar to children with FASD ADHD.
• Mattson et al., (2006)
• Children with FASDs have pervasive deficits in
  visual focused attention and deficits in
  maintaining auditory attention over time but no
  deficits in the ability to disengage and reengage
  attention with required to shift attention
  between visual and auditory stimuli although
  reaction times to shift were slower

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Misdiagnosis

• FASD versus ODD
• FASD Versus RAD
• FASD Versus Autism Spectrum Disorder

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Protective Factors

• Stable home
• Early diagnosis
• No violence against oneself
• More than 2.8 years in each living
• situation
• Recognized disabilities
• Diagnosis of FAS
• Good quality home from
• ages 8 to 12
• Basic needs met for at least
• 3/4th of the persons life

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Helpful Strategies for Parents

• Education that helps parents
• distinguish between I wont
• and I cant in their children.
• Parents have to think
• younger
• SELF Led Parenting helping
• parents to discover their
• own triggers and then
• resolving them.
• Respite in either direction
• Support groups.

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Helping a Child with FASD

• Graefe (2003)
• The 4 Ss C
• Structure, Supervision, Simplicity, Steps
• Context

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Strategies for Children with FASD
Working Memory Issues Yellow Stickies. What did
Ben do well today? Take a picture of the sand
tray. Bilateral Stimulation to keep something in
memory. IEP at school to accommodate this as a
brain based issue due to permanent impairment
from fetal alcohol exposure. External memory
reminders
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Example External Memory Reminders
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Chore Check List Example
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Strategies for Helping Children with FASD
Problems with Cause and Effect Let natural
consequences happen as long as they are not
dangerous or deadly. Writing for Greater Self
Knowledge Exercise Sheets Choices Have
Consequences EMDR protocol
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More Strategies

• Behavioral offenses
• ALWAYS have the child make amends in a concrete
  physical way.
• Teach for habituation rather then understanding
• Time management
• Describe time in TV episodes
• Affect Regulation
• Resource development with bilateral stimulation
• Deep breathing and body signal awareness
• Mindfulness techniques
• Drumming
• Self calming or self soothing strategies
• Find a nook or cranny for the child to tuck in.
• For motor coordination and self-esteem
• Feather exercise

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Resources

• SAMHSA FASD Center for Excellence
  fasdcenter.samhsa.gov
• Centers for Disease Control and Prevention FAS
  Prevention Team www.cdc.gov/ncbddd/fas
• National Institute on Alcohol Abuse and
  Alcoholism (NIAAA) www.niaaa.nih.gov/
• National Organization on Fetal Alcohol Syndrome
  (NOFAS) www.nofas.org
• National Clearinghouse for Alcohol and Drug
  Information ncadi.samhsa.gov
• Diagnostic Guide for Fetal Alcohol Spectrum
  Disorders The 4-Digit Diagnostic Code Third
  Edition (2004)
• http//depts.washington.edu/fasdpn
• These sites link to many other Web sites.

66
References

• American Academy of Pediatrics. (2000). Fetal
  alcohol syndrome and alcohol related
  neurodevelopmental
• disorders. Pediatrics, 106(2), 358-361.
• Astley, S., Stachowiak, J., Clarren, S.,
  Clausen, C. (2002). Application of the fetal
  alcohol syndrome facial photographic screening
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• Barr, H., Streissguth, A., Darby, B., Sampson,
  P. (1990). Prenatal exposure to alcohol,
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• Bennett, D., Bendersky, M., Lewis, M. (2008).
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• Bishop, S., Gahagan, S., Lord, C. (2007).
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• Duquette, C., Stodel, E., Fullarton, S.,
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67
References Continued

• FAS Diagnostic and Prevention Network. (2004).
  Diagnostic guide for fetal alcohol spectrum
  disorders The 4-digit diagnotic code (third
  edition). Washington University of Washington.
• Gomby, D. Shiono, P. (1991). Estimating the
  number of substance exposed infants. The Future
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• Hausknecht, K., Acheson, A., Farrar, A., Kieres,
  A., Shen, R., Richards, J., Sabol, K. (2005).
  Prenatal alcohol exposure causes attention
  deficits in male rats. Behavioral Neuroscience,
  119(1), 302-310.
• Jacobson, S., Stanton, M., Molteno, C., Burden,
  M. et al., (2008). Impaired eyeblink conditioning
  in children with fetal alcohol syndrome.
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• Kable, J., Coles, C., Taddeo, E. (2007).
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• Kalberg, W., Buckley, D. (2007). FASD what
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• Lawrence, R., Bonner, H., Newsom, R., Kelly, S.
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• Mattson, S., Calarco, K., Lang, A. (2006).
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• Niccols, A. (2007). Fetal alcohol syndrome and
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• OConnor, M., Frankel, F., paley, B., Schonfeld,
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68
References Continued

• Peadon, E., fremantle, E., Bower, C., Elliott,
  E. (2008). International survey of diagnostic
  services for children with fetal alcohol spectrum
  disorders. BMC Pediatrics, 8(12), 1-8.
• Premji, S., Benzies, K., Serrett, K., Hayden,
  K.A. (2006). Research-based interventions for
  children and youth with a fetal alcohol spectrum
  disorder Revealing the gap. Child Care, Health
  and Development, 33(4), 389-397.
• Rasmussen, C., Talwar, V., Loomes, C., Andrew,
  G. (2008). Brief report Lie-telling in children
  with fetal alcohol spectrum disorder. Journal of
  Pediatric Psychology, 33(2), 220-226.
• Schipper, W. (1991). Testimony before the U.S.
  House of Representatives Select Committee on
  Narcotics Abuse and Control. Retrieved from
  http//www.statistics .adoption.com
• Seigal, D. (1999). The developing mind. NY
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• Siegal, D. (2007). The mindful brain Reflection
  and attunement in the cultivation of well-being.
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• Streissguth, A., Kanter, K. (1997). The
  challenge of fetal alcohol syndrome Overcoming
  secondary disabilities. Washington University of
  Washington Press.
• Wattendorf, D., maj, U., Muenke, M. (2005). Fetal
  alcohol spectrum disorders. American Family
  Physician, 72(2), 279-285.
• Wedding, D., Kohout, J., Mengel, M., Ohlemiller,
  M., Ulione, M., Cook, K.., Rudeen, K.,
  Braddock, S. (2007). Psychologists knowledge and
  attitudes about fetal alcohol syndrome, fetal
  alcohol spectrum disorders, and alcohol use
  during pregnancy. Professional Psychology
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