Title: FASD and Behavioral Disorders in Context: Understanding Behavior of AlcoholAffected Children
1FASD 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
2Dr. 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
3Colleagues2005-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
4Atlanta 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
5The FAS Clinic
- A team of Professionals provides a diagnostic
evaluation to assess for teratogenic effects of
alcohol and drugs
6FAS 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
7POSSIBLE 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,
8SOME 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
9- 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
10The brain is the basis for
- Cognition (thinking)
- Attention
- Learning
- Language
- Motor Skills
- Behavior
- Emotion
11EFFECTS 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
12Normal development
Conception
Birth
Post Natal Experience
Outcomes
optimal
typical
nonoptimal
13Conception
Development affected by Teratogen and by
Postnatal Environment
EtOH
Birth
Post Natal Environment
Postnatal Experience
Outcomes
optimal
typical
nonoptimal
14FASD and Social Behavior
- What does the research tell us?
15(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
16Behaviors 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
17Effects of Confounding Factors
Prenatal alcohol exposure
Poverty
Disability
Behavior Disorder
Family Dysfunction
18 Problems in FAS Clinical Samples
- Mental Retardation/Low IQ
- Learning Disabilities
- Behavioral Disorders
- Attention Deficit/Hyperactivity Disorder (ADHD)
- Socialization
- Academic Failure
19Problems in Clinical Samples without FAS
- Mental Retardation/Low IQ
- Learning Disabilities
- Behavioral Disorders
- Attention Deficit/Hyperactivity Disorder (ADHD)
- Socialization
- Academic Failure
20(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
21Is 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
22Is 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?
23Can we identify neurobehavioral outcomes that are
the result of prenatal alcohol exposure?
24Is 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.
25Does 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
26Prenatal Alcohol Exposure and Behavior
- Cognition
- Arousal Regulation and Behavior Problems
- Social Behavior
- Substance Abuse
27The 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
28Functional 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
29Specific Problems Associated withFAS/pFAS and
maybe FASD
- Motor Problems
- Visual-Spatial Deficits
- Cognitive Deficits
- Working Memory
- Specific Academic Problems
30Problems 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
31Visual-Spatial Information
- Perceiving
- Judging
- Storing
- --Images
- --Symbols
- Experiencing
- --Space
- --Location
32Visual-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
33attentionWhat 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)
34Effects 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
35ADHD 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
36Factors 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
37Understanding Arousal Dysregulation
38Factors that lead to Arousal Dysregulation
- Temperament
- Brain Dysfunction
- Hyper-reactivity to environmental events
- Attachment difficulties
- Environmental Events
- Stress
39Alcohol 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
40Optimal 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)
41Does 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).
42Does 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
43Does 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)
44High 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
45(No Transcript)
46Predictors 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
47Source 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.
48Conclusions 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