FASD and Behavioral Disorders in Context: Understanding Behavior of Alcohol-Affected Children

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FASD and Behavioral Disorders in Context
Understanding Behavior of Alcohol-Affected
Children

• Claire D. Coles, PhD
• Building State Systems Annual Meeting
• San Antonio, Texas
• June 20-22, 2005

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Dr. Coles Affiliations

• Department of Psychiatry and Behavioral Sciences,
  Emory University School of Medicine, Maternal
  Substance Abuse and Child Development Laboratory
  (MSACD)
• Fetal Alcohol Center, Marcus Institute, Center
  for Developmental Disabilities

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Colleagues2005-Emory

• Roger Bakeman, PhD (GSU)
• Josephine V. Brown, PhD
• Caroline Drews-Botsch, PhD
• Arthur Falek, PhD (Retired)
• Paul Fernhoff, MD
• Felicia Goldstein, PhD
• Julie A. Kable, PhD
• Theresa Gauthier, MD
• Karen Howell, PhD
• Mary Ellen Lynch, PhD
• Laura Namy, PhD
• Kathleen A. Platzman, PhD
• Mary Ann Romsky, PhD (GSU)
• Biomedical Imaging Technology Center
• Xiaoping Hu, PhD
• Xiangyang Ma, PhD

• Khalil Abdur-Rashid
• John P. Berg
• Felicia Berry, MA
• Raemelle Edwards
• Zarina Fershteyn MPH
• Chris Foster
• Mark Granados
• Christy Hall, Ph.D.
• Katrina C. Johnston, MA
• Michael Marcin, MD
• Tuesday Means
• Lynne Padgett, PhD
• Monitinique Pierre
• Mark Register, PhD
• Susan Schmiedling, RN
• Sharron Paige-Whitaker
• Geke van der Ende, MA

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Atlanta Fetal Alcohol Study (1980-2008)

• Low SES, Predominantly African-American
• Identified in Prenatal Clinic based on
  Maternal Drinking
• Followed Longitudinally
• Funded NIAAA and Georgia DHR
• This study N265

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The FAS Clinic

• A team of Professionals provides a diagnostic
  evaluation to assess for teratogenic effects of
  alcohol and drugs

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FAS Center Staff
Claire D. Coles, Ph.D, Director Julie A. Kable,
Ph.D. Asst. Director

• FAS Clinic
• R. Dwain Blackston, MD
• Shena Leverett, LCSW
• Molly Millians, MEd
• Betsy Meeks, RN
• Jennifer Stapels, Ph.D.
• Mark Register, PhD
• Katrina C. Johnson, MA

• Research Staff and Colleagues
• Chris Cutcliffe, PhD
• Elles Taddeo, EdS
• Sam Maddox, MA
• Lynne Padgett, PhD
• Christy Hall, Ph.D.
• Virtual Reality Aids
• Dorothy Strickland, PhD

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POSSIBLE MECHANISMS OF DRUGS/ALCOHOL IN
PREGNANCY Teratogenic (Single Factor) Model
Outcome SIDS Fetal wastage Behavioral
effects Birth Defects Growth retardation
Teratogenic Substance
Fetus
Mother
Coles, 1995,
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SOME POSSIBLE MECHANISMS OF EFFECTS OF
DRUGS/ALCOHOL IN PREGNANCY Toxic (interactive)
Model
OUTCOMES Reduced fertility Fetal wastage Preterm
birth Birth defects Growth retardation Behavior
effects
Mother
Toxic Substance
Fetus
SECONDARY OUTCOMES Medical behavioral problems S
IDS
Coles, 1995
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• OUTCOMES
• Reduced fertility
• Fetal wastage
• Preterm birth
• Birth defects
• Growth
• Retardation

MULTI-FACTOR MODEL
Prenatal Environment Social Factors Legal
Issues Prenatal Care Substance Use
Abuse Maternal Characteristics Genetics
FETUS
SECONDARY OUTCOMES

• Developmental Medical
• Effects
• SIDS

MOTHER
POSTNATAL EVIRONMENT
Maternal Status/ Legal issues/ Social Factors/
Nutrition/ Substance Use Abuse/ Education /
Social Services/et cetera
Coles, 1995
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The brain is the basis for

• Cognition (thinking)
• Attention
• Learning
• Language
• Motor Skills
• Behavior
• Emotion

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EFFECTS OF PRENATAL ALCOHOL EXPOSURE ON CNS
Prenatal Exposure
CNS
RANGE OF EFFECTS
BRAIN DAMAGE Autopsy Reports Animal Models MRI
Studies Mental Retardation
MBD Animal Models MRI Borderline
IQ Behavioral Attention Deficits
LEARNING DISORDERS Longitudinal Clinical
Studies of FAS/FAE Exposed Children
BEHAVIOR DISORDERClinical Reports
UNAFFECTED Longitudinal Clinical Studies of
Exposed Children
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Normal development
Conception
Birth
Post Natal Experience
Outcomes
optimal
typical
nonoptimal
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Conception
Development affected by Teratogen and by
Postnatal Environment
EtOH
Birth
Post Natal Environment
Postnatal Experience
Outcomes
optimal
typical
nonoptimal
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FASD and Social Behavior

• What does the research tell us?

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(Some) Secondary Disabilities Attributed to
Prenatal Exposure

• Attention Deficit Hyperactivity Disorder
• Deficits in Executive Functioning
• Delinquency in Adolescence
• Substance Abuse
• Sexual Acting Out
• Assorted behavioral disorders

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Behaviors Attributed to Prenatal Alcohol-Exposure

• School Failure
• Impaired Judgement
• Delinquency in Adolescence
• Sexual Acting Out
• Substance Abuse
• Mental Illness
• Moral Depravity

• Impaired Memory
• Failure to Learn from Experience
• Lack of Generalization
• Lying
• Attachment Disorder
• No Conscience

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Effects of Confounding Factors
Prenatal alcohol exposure
Poverty
Disability
Behavior Disorder
Family Dysfunction
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Problems in FAS Clinical Samples

• Mental Retardation/Low IQ
• Learning Disabilities
• Behavioral Disorders
• Attention Deficit/Hyperactivity Disorder (ADHD)
• Socialization
• Academic Failure

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Problems in Clinical Samples without FAS

• Mental Retardation/Low IQ
• Learning Disabilities
• Behavioral Disorders
• Attention Deficit/Hyperactivity Disorder (ADHD)
• Socialization
• Academic Failure

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(Neuro) Behavioral Outcomes Examined in FASD

• General Cognitive/Learning Skills (IQ)
• Executive Functioning Skills
• Attentional regulation
• Memory,Planning and organization
• Motor skills
• Visual/spatial skills
• Academic Achievement
• Adaptive Behavior
• Social Behavior
• Mental Health/Behavioral Disorders

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Is there a unique signature?
What are the neurodevelopmental outcomes of
exposure to a teratogenic agent?

• Heavy Exposure?
• Teratogenic outcomes (mortality, Dysmorphia,
  growth retardation, neurological damage)

• Behavioral Phenotype?
• Specific areas of deficit attributed to exposure
  to specific drugs

• Global Effect?
• Early insults to brain result in widespread,
  relatively mild effects

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Is there a Unique Effect of Prenatal Alcohol
Exposure on Behavior?

• Can we identify neurobehavioral outcomes that are
  the result of prenatal alcohol exposure?
• Is there a distinct pattern that can be used for
  diagnosis in the absence of knowledge of prenatal
  exposure?
• Does it matter?

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Can we identify neurobehavioral outcomes that are
the result of prenatal alcohol exposure?

• Yes

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Is there a distinct pattern of behavior that can
be used for diagnosis in the absence of knowledge
of prenatal exposure?

• Not right now. Maybe never.

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Does it Matter?

• Yes and No
• Yes, that it would be convenient and
  scientifically interesting
• No, in that clinically we need to treat those
  who come to our attention

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Prenatal Alcohol Exposure and Behavior

• Cognition
• Arousal Regulation and Behavior Problems
• Social Behavior
• Substance Abuse

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The Brain is Plastic

• It grows and changes with experience
• Zero to two is the brain growth time
• It is constantly rewired by experience
• Learning continues over the life span
• education is the method

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Functional Deficits Identified in
Alcohol-Affected Individuals

• General Cognitive/Learning Skills (IQ)
• Executive Functioning Skills
• Attentional/arousal regulation
• Memory
• Planning and organization
• Academic Achievement
• Math ability

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Specific Problems Associated withFAS/pFAS and
maybe FASD

• Motor Problems
• Visual-Spatial Deficits
• Cognitive Deficits
• Working Memory
• Specific Academic Problems

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Problems with Motor functioning

• Poor muscle tone
• Use utensils
• Tie Shoes
• Balance
• Fine motor skills
• handwriting
• Use of scissors
• Gross motor skills
• Running
• Riding a bike

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Visual-Spatial Information

• Perceiving
• Judging
• Storing
• --Images
• --Symbols
• Experiencing
• --Space
• --Location

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Visual-Spatial Deficits

• Difficulty judging
• Patterns
• Shapes
• Relationships in space
• Confusion over left-right
• Spatial Memory
• Problems storing visual images in short and long
  term memory
• Symbol recognition
• Failure to use mental imagery

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attentionWhat is it? Whats a problem in FAS?

• Noticing (orienting)
• Arousal Regulation
• Focusing (on the right thing)
• Sustaining Attention
• Encoding Information (entering it)
• Shifting Attention (when it is time)

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Effects on Information Processing and Attention
at 7 years.

• Slower, less efficient encoding of visual
  information.
• Specific Deficits in Math Skills.

Coles, et al, (1997) A comparison of children
affected by prenatal alcohol exposure and
attention deficit hyperactivity disorder ACER,
21, 150-161
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ADHD vs. FAS

• ADHD
• Problem focusing attention
• Problem inhibiting impulsive behavior
• High activity level and behavior problems

• FAS
• Problems learning information
• Slower processing
• Less efficient processing of visual information
• Problems with flexibility in problem solving

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Factors Leading to confusion re Attention and
ADHD

• Diagnosing ADHD
• Confusing clinical and experimental Contexts
• Defining attention
• Failing to discriminate attention from other
  cognitive constructs like memory and executive
  functioning

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Understanding Arousal Dysregulation
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Factors that lead to Arousal Dysregulation

• Temperament
• Brain Dysfunction
• Hyper-reactivity to environmental events
• Attachment difficulties
• Environmental Events
• Stress

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Alcohol and drug exposure

• Research indicates that
• Newborns have higher heart rates
• Infants show more sleep disorders
• More problems in self-consoling
• Arousal regulation and attention
• Difficulties with self-regulation and Aggression
  at 24 months

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Optimal Arousal Levels

• There is an optimal arousal level for various
  human activities (e.g., sleep, attention,
  activity).
• There is an optimal level for each person
  (experienced as affect state)
• We strive to achieve this optimal level (e.g.,
  coffee, food, music, alcohol, physical arousal,
  exercise, etc)

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Does alcohol exposure predispose a child to later
drug abuse?

• 30 - 40 of FAS/pFAS population reported alcohol
  and other drug abuse problems, ages 12 - 20 for
  ages 21 - 51, 30 to 70.
• (Streissguth, 1996).

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Does alcohol exposure predispose a child to later
drug abuse?

• Lower rates than national sample 71 of 10th
  graders vs. 50 of FAS/pFAS sample of 15 year
  olds reported any use of alcohol
• Lower rates of cigarette use 58 national sample
  vs. 29 of FAS/pFAS
• Illicit drug use was very rare among our 15 year
  olds

Coles, et al. , 1999
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Does Alcohol Exposure Predispose A Child to
Delinquent Behavior?

• 60 of FAS/pFAS clients experienced trouble with
  the law (Streissguth, 1996)
• Prenatal exposure associated with delinquency and
  criminal behavior (Fast et al., 1999)

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High Levels of Delinquency May Not be Typical of
Most Adolescents with FAS

• Many of these studies have been completed based
  on samples of teens who already have been
  referred for professional services because of
  behavioral problems
• These teens are probably the most severely
  affected and not representative of the broader
  spectrum of alcohol-affected adolescents

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Predictors of Delinquency Atlanta FAS Sample

• Externalizing behaviors
• Self-reported substance abuse
• Higher number of negative life events
• Lack of supervision
• Inconsistent discipline provided by caregivers

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Source Lynch, et al. (2003) Examining
delinquency in adolescents differentially
prenatally exposed to alcohol. J Stud Alcohol,
64, pp. 678-686
It is widely reported that prenatal alcohol
exposure is associated with later criminal
behavior. But most studies didnt controlled for
environmental factors.
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Conclusions FAS and Delinquency

• Delinquent behavior more strongly related to
  current environmental factors such as stressful
  life events and parental characteristics and
  behavior than to prenatal exposure to alcohol
• Important to examine current family, peer and
  community influences in addition to exposure
  status