Prenatal Alcohol Exposure

1
Prenatal Alcohol Exposure

• Alcohol is a known teratogen.
• Teratogens are substances that, when exposed to a
  developing fetus, impair normal development and
  cause birth defects in prenatal development.
• Teratogens can result in (Streissguth 1997)
• death
• malformations
• growth deficiency
• functioning deficits
• Teratogens may have a dose-response effect, in
  that as the dose of the teratogen increases the
  deficits and impairments also increase.

2
Prenatal Alcohol Exposure

• Alcohol has an interaction effect on development
  alcohol interacts with the genes to produce
  impairments in offspring.
• Not all children exposed to the same amount of
  alcohol will show similar deficits. Some children
  exposed to higher levels of alcohol may have less
  severe deficits than others exposed to lower
  levels or at different times during pregnancy.
• In fact, the timing of the exposure during
  pregnancy, amount of alcohol consumed, other drug
  use, genetics of mother and children, stress,
  mothers ability to metabolize alcohol, and age of
  mother may all interact to produce various
  deficits. (Malbin, 2002)

3
PAE during the first trimester generally results
in damage to physical structure and PAE during
the third trimester typically affects growth or
size of the fetus. The brain (CNS) develops
throughout the entire pregnancy, and is affected
by alcohol exposure at any time during pregnancy
(Streissgith, 1997).
Malbin (2002)
4
Fetal Alcohol Spectrum Disorder (FASD)

• Prenatal alcohol exposure produces a range of
  effects including
• Fetal Alcohol Syndrome (FAS)
• Fetal Alcohol Effect (FAE)
• Fall under the new category of FASD
• FASD refers to individuals who may have physical,
  mental, behavioral, and/or learning disabilities
  as a result of maternal alcohol consumption
  (Chudley et al., 2005).

5
Fetal Alcohol Syndrome (FAS)

• FAS was first identified in 1973 by Jones
  Smith, based on case observations in which
  clinicians noted a similar pattern of
  malformations among infants born to alcoholic
  mothers.
• Similar effects of prenatal alcohol exposure were
  noted by Lemoine and Colleagues in France (1968).

6

• FAS is characterized by
• growth deficiency in weight and or height
• facial features that may include short palpebral
  fissures (eye length), smooth philtrum (groove
  above upper lip), thin upper lip, flat midface,
  and short nose
• damage to the CNS as indexed by microcephaly,
  cognitive deficits, learning problems,
  attentional difficulties, hyperactivity, and/or
  motor problems

7
From Streissguth and Little (1994).
8
Fetal Alcohol Effects (FAE)

• FAE was used to refer to children who did not
  have all the characteristics of FAS (usually
  absence of some or all facial features and/or
  lack of growth deficiency) but still had PAE and
  some CNS dysfunction (Clarren and Smith 1978).
• The Institute of Medicine (IOM) identified 3
  classifications of Fetal Alcohol Effects
• Alcohol Related Neurodevelopmental Disorder
  (ARND) refers to individuals with alcohol
  exposure and CNS and neurobehavioral deficits.
• Alcohol-Related Birth Defects (ARBD) refers to
  individuals with some congenital physical
  abnormalities as a result of alcohol exposure
  (heart, vision, hearing, skeletal problems).
• Partial FAS refers to individuals with some
  facial characteristics, and either growth or CNS
  deficits

9
FASD

• Previously used diagnostic categories tended to
  focus on the presence or absence of facial
  dysmorphology.
• With research we have learned that relatively few
  children prenatally exposed to alcohol have all
  of the physical features required to diagnose
  FAS.
• The FAS facial features occur during a short
  period of vulnerability early in the first
  trimester (based on a mouse model) (Sulik et al.,
  1981).
• The neurobehavioral consequences of prenatal
  alcohol exposure can occur with exposure
  throughout pregnancy.

10
From Sulik K, Johnston M, Webb M. Fetal alcohol
syndrome embryogenesis in a mouse model. Science
1981214936-8.
11
FASD

• Studies directly comparing the degree of
  neuropsychological impairments in those with and
  without the physical features of FAS yield no
  meaningful differences
• The neuropsychological deficits associated with
  prenatal alcohol exposure appear to be
  independent of the physical characteristics of
  FAS.
• The spectrum approach to terminology is
  advantageous over previous categorical
  approaches, because diagnosis of an FASD focuses
  more on CNS deficits as these are of greater
  functional significance than the physical
  features.

12
(No Transcript)
13
FASD

• The incidence of FASD is estimated to range from
  3-10 /1000 births.
• FASD is one of the most common known cause of
  mental retardation.
• Lifetime cost of FASD is estimated to be 1.5 - 2
  million per person.
• A recent Canadian study estimates annual costs of
  FASD at 344,208,000 for care of those less than
  21 years of age.

14
Diagnosis of an FASD

• Chudley et al. recommend evaluating
• Growth
• Facial Features
• Neurobehavioral Functioning
• Alcohol exposure
• Physical features are not required for a
  diagnosis of an FASD.

15
Confirmation of Alcohol Exposure

• Challenges
• Birth mother no longer available
• Unreliable self-report
• Forgetfulness
• Conflicting reports
• Biomarkers for PAE
• Fatty Acid Ethyl Esters (FAEE)
• Found in meconium and hair of newborns
• Research studies find high rates of FAEE

16
Neurobehavioral Assessment

• Hard and soft neurological signs
• Brain structure (MRI, head circumference)
• Cognition (IQ)
• Communication (receptive and expressive)
• Academic achievement
• Memory
• Executive functioning and abstract reasoning
• Attention/hyperactivity
• Adaptive behavior, social skills, social
  communication.
• Chudley et al., 2005

17
Behavioral Phenotype (Kodituwakku, 2007)

• A characteristic pattern of motor, cognitive,
  linguistic, and social observations consistently
  associated with a biological disorder (OBrien
  Yule, 1995)
• Causal connections between PAE and
  neurobehavioral effects are difficult to make
  because of the interaction of environmental and
  genetic factors.

18
Cognitive Functions (Kodituwakku, 2007)

• Intellectual ability decreased IQ in children
  and adults with FASD.
• Some dose-dependent effects
• Deficits in both verbal and performance aspects
• Attention and speed of processing
• Significant deficits in sustained and focused
  attention.
• Slower processing speed

19
Cognitive Functions (Kodituwakku, 2007)

• Executive Functioning (EF) higher-order
  cognitive processes involved in goal-oriented
  behavior.
• The EF deficits in FASD have been documented on
  tests of cognitive flexibility, inhibition,
  planning and strategy use, concept formation,
  verbal reasoning, set-shifting, working memory,
  and fluency all cognitive-based or cool EF
  tests.
• Also show deficits on hot EF tests assessing
  emotion-related behaviors and decision making.

20
Cognitive Functions (Kodituwakku, 2007)

• Language some mixed effects, but children with
  FASD generally have poorer language abilities.
• Visual Perception most impaired on tasks that
  involve integration of information, planning, and
  visual-motor integration.
• Learning and Memory slower at learning
• Deficits on both visual and verbal memory tasks.

21
Cognitive Functions (Kodituwakku, 2007)

• Number Processing although children with FASD
  have difficulties in many academic areas, math
  appears to be the most severely affected.
• Streissguth et al. (1994) conducted a large
  longitudinal study on children with PAE.
• Out of many cognitive and academic tests, math
  was the most difficult and most highly correlated
  with PAE.
• These math deficits were stable over time
• Effects were generally dose-dependent
• Math deficits in FASD are even lower than
  expected based on IQ scores.

22
Behavioral Dysfunction (Kodituwakku, 2007)

• Classroom Behaviors distractible, inattentive,
  hyperactive, restless
• Adaptive Behavior personal and social skills
  needed to live independently
• Most deficits in social skills, interpersonal
  relationships
• One study of adolescents and adults with FASD
  (mean age 17 years) found adaptive functioning
  skills to be at the level of a 7-year-old
  (Streissguth et al., 1991)
• Emotional Functioning mental health disorders
  and emotional difficulties

23
Atypical Brain Development (Kodituwakku, 2007)

• Decrease in white matter and overall brain size
• Abnormalities in
• Frontal lobe
• Corpus Callosum
• Basal Ganglia
• Cerebellum
• Diffusion Tensor Imaging

24
FASD and Risky Behaviors (Rasmussen Wyper, 2007)

• Primary disabilities those which directly result
  from the brain injuries of PAE and are evident in
  some form from birth.
• Intelligence, memory, attention
• Secondary Disabilities result from primary
  disabilities and environmental interactions and
  are not evident from birth
• In theory they are preventable with better
  understanding of appropriate interventions

25
Secondary Disabilities

• Streissguth et al. (1996) conducted a
  longitudinal study on secondary disabilities in
  FASD.
• The Life History Interview (LHI), which measures
  common secondary disabilities, was administered
  to 415 individuals (6-51 years old) with FAS and
  FAE.
• The results were astounding
• More than 90 of the sample had mental health
  problems
• 49 of the adolescents/adults and 39 of the
  children demonstrated inappropriate sexual
  behaviors

26

• More than 60 of adolescents/adults and 14 of
  the children had disrupted school experience
• 60 of adolescents/adults and 14 of the children
  had been in trouble with the law
• 50 of the adolescents/adults had been confined
  (e.g. incarceration, inpatient mental health
  programs, or alcohol and drug treatment programs)
• 35 of the adolescents/adults had alcohol and
  drug problems.
• 67 had experienced physical or sexual abuse, or
  were victims of domestic violence
• 80 were not reared by their biological mother

27
Risk Factors

• Three risk factors were identified that were
  associated with higher rates of secondary
  disabilities
• being diagnosed with FAE rather than FAS
• having an IQ above 70
• higher scores on the Fetal Alcohol Behavior
  Scale which measures behaviors of fetal
  alcohol exposure
• Thus, having less severe physical effects (FAE
  instead of FAS) and a higher IQ were associated
  with a higher rate of secondary disabilities.

28
Protective Factors

• Streissguth et al identified 5 protective factors
  that resulted in lower rates of secondary
  disabilities
• living in a good quality stable home environment
• infrequent changes in living arrangement
• not being exposed to violence
• receiving services for developmental disabilities
• being diagnosed before the age of 6

29
Delinquency and FASD

• Maladaptive behaviors impulsivity,
  teasing/bullying, dishonesty (lying, cheating,
  stealing), avoiding school or work, destruction
  of property, physical aggression, and self-injury
  behaviors (LaDue et al, 1992).
• FASD linked to behavior problems and delinquency
  in adolescents (Carmichael Olson et al., 1997).
• Children with PAE have higher rates of delinquent
  behaviors than children with ADHD, including
  cruelty, bullying (48 of children), lying or
  cheating (90 of children), and stealing.
• 97 children with fetal alcohol exposure lacked
  guilt after misbehaving. Nash et al (2006)

30
Delinquency and FASD

• PAE is also associated with conduct behaviors and
  lower overall moral maturity (Schonfeld et al.,
  2005)
• Home environment related to delinquency in that
  youth living in biological or foster homes were
  more likely to engage in delinquent behaviors
  than youth living in adoptive homes.
• It is clear that individuals with FASD are
  particularly prone to delinquent behaviors
  however some researchers suggest that this may be
  due to factors (e.g., family and individual
  characteristics) other than prenatal alcohol
  exposure (Lynch et al, 2003).

31
FASD and the Criminal Justice System

• Adolescents and adults with FASD are at
  particular risk for ending up in the criminal
  justice system.
• In Streissguths studies 60 of adolescents and
  adults with FASD had been in trouble with the law
  and 50 had been confined.
• A Canadian study found that 23 of youth remanded
  for a psychiatric inpatient assessment had an
  FASD (Fast et al., 1999).
• A recent Canadian report indicated that 10 of
  inmates had an FASD, which is 10 times higher
  than in the general population (Sandrers, 2007).

32
FASD and Psychopathology

• High rates of psychiatric disorders among
  children with PAE 87 met criteria for a
  psychiatric disorder including mood disorders
  (61), bipolar disorder (35), major depressive
  disorder (26) (OConnor et al., 2002)
• PAE is linked to depressive symptoms among
  6-year-old girls (OConnor et al., 2001).
• In one study 97 of the alcohol-exposed children
  were diagnosed with an axis 1 disorder (Fryer et
  al., 2007)
• ADHD, depressive disorders, oppositional defiant
  disorder (ODD), conduct disorder (CD), phobias
• Adults with binge alcohol exposure have higher
  rates of many disorders including somatoform,
  substance dependence/abuse, paranoid,
  passive-aggressive, antisocial, and personality
  disorders (Barr et al (2006)

33
FASD and Substance Abuse

• PAE is associated with alcohol problems in
  adolescents and adults (Baer et al. 2003)
• In one sample of adults with PAE, 25 had an
  alcohol disorder. (Alati et al., 2006)
• PAE is associated with the development of
  nicotine, alcohol and illicit drug dependence,
  even when biological parental alcohol abuse is
  controlled for. (Yates et al, 1998).

34
FASD and Suicidality

• Adolescents and adults with FASD are at risk for
  suicide and attempted suicide.
• OMalley and Huggins (2005) carried out a pilot
  study of 11 individuals affected by FASD.
• Over half (6) of the participants reported
  attempted suicide, a rate that is drastically
  higher than the general Canadian population rate
  of 4.6.

35
Factors Relating to Risky Behaviors in FASD

• The significant EF deficits in individuals with
  FASD likely contribute to high risk behaviors.
• Impairments in EF skills such as planning,
  cause-effect reasoning, learning from past
  mistakes, and the lack of social adaptability may
  be related to why youth with FASD are
  overrepresented in the justice system.
• The connection between poor executive functioning
  and juvenile delinquency has been well-documented
  in other populations.
• Adolescent/adult offenders are impaired on many
  tests of EF
• Inhibition appears to be one aspect of EF that is
  strongly related to delinquency and high risk
  behaviors.

36
Factors Relating to Risky Behaviors in FASD

• Poor decision making is linked to the frontal
  lobe
• Individuals with frontal lobe damage show similar
  risky and maladaptive behaviors as those with
  FASD.
• PAE has a negative effect on the frontal cortex,
  thus putting individuals with FASD at increased
  risk for engaging in problematic behaviors.
• Risk taking increases during adolescence because
  they are more sensation-seeking and reward-driven
  but have a prefrontal cortex that is still
  developing.
• In FASD, adolescence is a time of heightened
  vulnerability, as these individuals have even
  more of a gap between their brain/cognitive
  development and their behaviors.