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Fetal Alcohol Spectrum Disorders: Diagnosis,
Prevention and Intervention
Roger J. Zoorob, MD, MPH, FAAFPFrank S. Royal Sr. Professor and Chair
Department of Family & Community Medicine
Meharry Medical College
Professor and Director Family Medicine
Vanderbilt University – Nashville, TN
Objectives
1. Examine diagnostic criteria for FAS
2. Review diagnostic criteria of FASDs
3. Review FASDs prevention/alcohol screening.
4. Discuss intervention & treatment options
Barriers We Face as Providers
Prevention of Alcohol Use among Pregnant Women Lack of training Uncertain about how to intervene if problem is found Time constraints Personal discomfort
Diagnosis and Care of Children with FASDs Lack of training Uncertain about how to intervene if problem is found Fear of offending mother Belief that the harm is already done
Weisner C, Matzger H. Alcohol Clin Exp Res. 2003 Jul;27(7):1132-41; Nevin AC et al. BMC Fam Pract. 2002;3:2.
Zoorob R, Aliyu MH, Hayes C. Alcohol. 2010 Jun;44(4):379-85.
Criteria for DiagnosingFetal Alcohol Syndrome (FAS)
With or w/o confirmed fetal exposure to alcohol, diagnosis requires documentation of:
1.All three dysmorphic facial features (smooth philtrum, thin vermillion border, small palpebral fissures)
2.Prenatal or postnatal growth deficit in height or weight
3.CNS abnormality: structural, neurological, or functional
Bertrand J, Floyd RL, Weber MK. Guidelines for Identifying and Referring Persons with Fetal Alcohol syndrome. Morbidity and Mortality Weekly Review. October 28, 2005/54;1-10
Facial Abnormalities Of FAS
1. Smooth philtrum
2. Thin vermillion
3. Small palpebral fissures
Photo courtesy of Teresa Kellerman
Lip-Philtrum Guide
Developed by University of Washington FAS Diagnostic & Prevention Network
Guide 1 – Caucasians
Guide 2 – African AmericansBack side provides face &
height-weight tables from the FASD Diagnostic Guide (2004)
Order fromhttp://depts.washington.edu/fasdpn/htmls/order-forms.htm
http://fasdcenter.samhsa.gov/educationTraining/courses/CapCurriculum/competency2/facial2.cfm
Palpebral Fissure Measurement
www.fasdpn.org
Measuring the Palpebral Fissures
Astley, et al. Magnetic Resonance Imaging Outcomes From a Comprehensive Magnetic Resonance Study of Children With Fetal Alcohol Spectrum Disorders. Alcoholism: Clinical and Experimental Research, Oct 2009.
Photo courtesy of the University of Louisville Fetal Alcohol Spectrum Disorders (FASD) Clinic - Weisskopf Child Evaluation Center, and the FASD Southeast Regional Training Center at Meharry Medical College Department of Family and Community Medicine: FASDsoutheast.orgAny use of this photo requires written permission from the University of Louisville FASD Clinic - Weisskopf Child Evaluation Center and the proper acknowledgement as written in this caption.
Photo courtesy of the University of Louisville Fetal Alcohol Spectrum Disorders (FASD) Clinic - Weisskopf Child Evaluation Center, and the FASD Southeast Regional Training Center at Meharry Medical College Department of Family and Community Medicine: FASDsoutheast.org Any use of this photo requires written permission from the University of Louisville FASD Clinic - Weisskopf Child Evaluation Center and the proper
acknowledgement as written in this caption.
#2 Growth Deficits in FAS Timing
– Prenatal or Postnatal– At any one point
Degree– ≤ 10th percentile for age and sex
adjusted for gestational age Height or Weight (or Head
Circumference)
UCLA RTC
Growth Deficiency (weight and/or height) ≤10% at any one point pre- or postnatal
(adjusted for age, sex, gestational age, race/ethnicity)
#3 CNS Abnormalities of FAS
Documentation of any of the following Structural Abnormality
Head circumference ≤ 10%’ (adjusted for age, sex) Clinically meaningful brain abnormalities observed
through imaging (reduction in size or change in shape of corpus callosum, cerebellum, or basal ganglia)
Bertrand J, Floyd RL, Weber MK. Guidelines for Identifying and Referring Persons with Fetal Alcohol syndrome. Morbidity and Mortality Weekly Review. October 28, 2005/54;1-10
#3 CNS Abnormalities of FAS Neurologic Abnormality
– Motor problems or seizure NOT from a postnatal insult or fever – Other soft neurologic signs outside normal limits
Functional Abnormality– Global cognitive or intellectual deficits (IQ <3rd percentile)– Substantial developmental delay in younger children – Functional deficits (<16th percentile) in at least 3 domains:
Cognitive or developmental deficits Executive functioning
Abstract concepts Problem solving
Motor functioning Attention problems/hyperactivity
Social skills Other (sensory, memory, language)
Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005/54;1-10
Incidence of FAS
Comparable with or higher than rates for other common developmental disabilities (Down’s syndrome, spina bifida)
0.2 to 1.5 cases of FAS per 1,000 live births in the US
Approximately 4 million infants are born in the US per year
An estimated 1,000--6,000 are born with Fetal Alcohol Syndrome
CDC. MMWR Morb Mortal Wkly Rep 2002;51:433-435.
What are FASDs?
“Fetal Alcohol Spectrum Disorder” is NOT a diagnostic category, but rather an umbrella term describing a range of effects that can occur in a person whose mother drank alcohol during pregnancy
Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005 / 54;1-10.
From FAS Diagnostic Criteria to Life with an FASD….
IQ averages 60, range 20-110 Poor Judgment Problems with
– Behavior– Motor Skills– Social Interactions
Excessive body contact
Impulsiveness
Intrusiveness
Lack of stranger anxiety
www.cdc.gov/ncbddd/fasd/videos/Iyal/long/Iyal_long.html
Beyond Early Childhood
Difficulties Socializing– Maintaining Friendships– Depression and Anxiety – Inappropriate Sexuality
…. Even Beyond Early Childhood
Disrupted Schooling– 43% of teens with FASDs are at high risk of
having school interrupted by suspension, expulsion, or from dropping out
Conduct Problems– Antisocial Behaviors– Inability to follow rules, lying, and stealing
GOALIndependent Living
Socialization Issues
Excessive body contact(Do not understand personal space)
Impulsiveness
Intrusiveness(Miss social cues for making/keeping
friends)
Lack of stranger anxiety(Easily victimized/sexually abused)
Kindergarten – Sixth Grade
Easily influenced by others Memory loss and retrieval problems. Needs things
repeated multiple times and still may not retain information.
Lying, stealing, or disobedient Problems separating fantasy from reality, having a
different perception of reality Temper tantrums Delayed physical, academic, and/or social development Silence, retreating from situations Inappropriate social behavior
Middle School/Junior High
Self-centered (act younger than stated age) Criminal activity Poor reasoning skills Cognitive problems from previous section do
not improve (memory, recall, reality, etc.) Poor motivation, low self-esteem, depression Academically tops out in one or more subjects Sexually active, drug or alcohol use Lacks time management skills, no concept of
time
Actual Age: 18
Expressive Language ----------------------------------- 20
Comprehension ------- 6
Money, time concepts ------- 8
Emotional maturity ---- 6
Physical maturity ---------------------------------- 18
Reading Ability ------------------------------- 16
Social Skills ---------------- 7
Living Skills --------------------- 11
Secondary Disabilities
Mental health problems-more than 90% Alcohol and other drug problems-35% of
adolescents and adults Disrupted school experiences->60% Juvenile justice 60% Juvenile confinement 40%
Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Brookes Publishing. ISBN 1-55766-283-5
Co-occuring conditions in FASD
Attention-Deficit/Hyperactivity Disorder (ADHD)Oppositional Defiant Disorder (ODD)Conduct Disorder (CD)Reactive Attachment Disorder (RAD)Sleep DisordersSchizophreniaDepressionBi-polar disorderSubstance use disordersPost-Traumatic Stress Disorder (PTSD)
Protective Factors
Living in a stable and nurturing home for over 72% of life Being diagnosed with FAS before age six Never having experienced violence Remaining in each living situation for at least 2.8 years Experiencing a "good quality home" (meeting 10 or more defined
qualities) from age 8 to 12 years old Having been found eligible for developmental disability (DD)
services Having basic needs met for at least 13% of life Having a diagnosis of FAS (rather than another FASD condition)
Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Brookes Publishing. ISBN 1-55766-283-5.
Prevention is first but for those cases that
were not prevented
FASDs Interventions and Treatments
Intervention Strategies1. Appropriate developmental services
2. Appropriate educational services (8 Magic Keys, Socio-cognitive habilitation/math interactive learning experience)
3. Neurobehavioral reframing/paradigm shift/parent coaching
4. Advocacy in multiple settings, specifically SCHOOL and WORKPLACE
5. Emphasizing strengths
6. Treatment of co-occurring conditions (including medication management)
7. Social skills training
Multidisciplinary Approach is Critical
Medical Treatment Mental Health Treatment
– Pharmacotherapy– Behavioral Therapies and Interventions
Skilled Nursing Services Physical, Occupational, and Speech Therapy Educational Interventions
– Early Intervention Services– Exceptional Ed– Teacher In-Service Training
Green JH. Fetal Alcohol Spectrum Disorders: Understanding the Effects off Prenatal Alcohol Exposure and Supporting Students. Journal of School Health. March 2007;77:103-108.
Multidisciplinary Approach is Critical
Caregiver Support Parent Training Case Management Art and Music
Therapy Service Animals
…. and more….
www.cdc.gov/ncbddd/fasd/videos/Iyal/long/Iyal_long.html
Intervening with Youth and Young Adults with FASDs
Purpose: CDC-supported innovative research to identify and evaluate interventions 16-25 year olds with FASDs – Randomized control design (at least 50 per group)– Comprehensive medical, psychological, &
environmental assessment– Comprehensive referrals and targeted intervention– Caregiver education/support
Funded: – UCLA
Project Step Up: decrease alcohol use– Saint Louis University
Partners for Success: family therapy, life coaching
Stomach
Brain
Liver
Kidneys
Fetus
Muscles
Nerves
Placenta
Brain
Heart
Organs
Breast
No known safe amount of alcohol to drink while pregnant
Major Effects of Ethanol by Trimester of Pregnancy
The most prudent advice you can give to all women is to stop drinking before conception and to maintain abstinence through-out
pregnancy and during breast feeding. (UCLA RTC)
In 2008, about 7.2% of pregnant women used alcohol
1 of 20 pregnant women drank excessively before finding out they
were pregnant.
Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System prevalence data. Atlanta, GA: Centers for Disease Control and Prevention. Available at www.cdc.gov/brfss.
Floyd RL, Decoufle P, Hungerford DW. Alcohol use prior to pregnancy recognition. Am J Prev Med 1999;17(2):101–107
SAMHSA 2010 National Survey on Drug use and Health
57% women of childbearing age (15-44) currently drink
From 2009-2010, an average of 11% of pregnant women reported current alcohol use, 4% reported binge drinking and 1% heavy drinking
Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.
Alcohol Consumption Rates for the Southeast Region
39% males, 36% females reported any drinking in past 30 days
28% males reported binge drinking (5 or more drinks/occasion) and 25% of female reported binge drinking (4 or more drinks/occasion)
Behavioral Risk Factor Surveillance System, 2010
Alcohol Consumption Rates for the Southeast Region
Among women of childbearing age, 42% consumed any alcohol and 26% reported binge drinking in the past 30 days
Among pregnant women, 6% reported any alcohol use and 24% reported binge drinking in past 30 days
State-Specific Weighted Prevalence Estimates of Alcohol Use Among Women 18–44 Years of Age, Behavioral Risk Factor Surveillance System, 2010
Alcohol Assessment and Intervention in Primary Care
Ask, Assess, Advise and Assist
Alcohol Assessment: Know what a Standard Drink is:
At-Risk Drinking
Per Week Per Occasion
Men > 14 drinks > 4 drinks
Women > 7 drinks > 3 drinks
Seniors > 7 drinks > 1 drink
Alcohol Assessment: Frequency and Quantity
First ask: Do you drink alcohol, including beer, wine or distilled spirits?
On average, how many days per week do you drink alcohol?
On a typical day when you drink, how many drinks do you have?
What’s the maximum number of drinks you had on a given occasion in the last month?
TWEAK Alcohol Assessment
Developed originally to screen for at-risk drinking during pregnancy
Five-item scale Shown effective in pregnant women
“TWEAK” T-Tolerance: "How many drinks does it take you
to feel the first effects of the alcohol?" W-Worry: "Have close friends or relatives
Worried or complained about your drinking in the past year?"
E-Eye-openers: "Do you sometimes take a drink in the morning when you first get up?"
A-Amnesia (blackouts); "Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?"
K(C)-Cut Down: "Do you sometimes feel the need to Cut Down on your drinking?"
Tweak Scoring Tolerance: 3 or more drinks to feel effect = 2
points Worry: Yes = 2 points Eye Opener: Yes = 1 point Amnesia: Yes = 1 point Cut Down: Yes = 1 point
A score of >0 indicates at-risk during pregnancyFor others, a score of 2 indicates likelihood of at-risk drinking; A score of 3-4 or more indicates problem drinking or alcoholism
Chang G. Alcohol Screening Instruments for Pregnant Women. Alcohol Research and Health. 2001;25(3):204-209 (at NOFAS website)
The CRAFFT
Brief Intervention Treatment
Found to be effective with women problem drinkers in primary-care clinics
5-10 minute counseling session has been found to reduce alcohol use in women by 20-30%
… is not difficult
Wallace P, Cutler S, Hains A. Randomized controlled trial of general practitioner in patients with excessive alcohol consumption. British Medical Journal. 1988;297(6649):663-668.Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers: A randomized controlled trial in community-based primary-care practices. JAMA. 1997;277(13):1039-1045.
Brief Intervention: Ask and Assess Risk Level
1. Raise the subject: Alcohol Assessment Test“I like to ask all my patients about their drinking patterns”
2. Does the patient have alcohol-related problems? (Medical, behavioral, social, familial)
3. Provide feedback about alcohol risk level: Relate health concerns / pregnancy risks to alcohol use
“I am very concerned about how your drinking may affect your health”
“There is no known safe limit for drinking during pregnancy. You need to stop drinking completely b/c when you drink, your baby drinks.”
Brief Intervention: Advise and Assist
4. Engage the patient in the process: Assess, enhance motivation and patient responsibility“How do you feel about your drinking?”
5. For alcohol-risk, establish drinking goals: Advise and negotiate cut down “Are you ready to set a drinking goal? What do you think will work best for you?” (give brochure materials)For alcohol dependence, advise abstinence and refer to specialized treatment.
6. Follow up: review progress, commend effort, reinforce positive change, reassess motivation
National Institute on Alcohol Abuse and Alcoholism and Office of Researchon Minority Health, Identification of At-Risk Drinking and Intervention with
Women of Childbearing Age. NIH Publication No. 99-4368 (Printed 1999)
Information and Treatment Resources
Southeast Fetal Alcohol Spectrum Disorders Regional Training Center
Meharry Medical College Dept. of Family Medicine – Nashville, TNTel: (615) 327-5525
University of Louisville Weisskopf Child Evaluation Center - Louisville, KY
Tel: (502) 852-3020
http://www.fasdsoutheast.org
Information and Treatment Resources
The Arc of the United States– The Arc of South Carolina - Tel (803) 748-5020
www.arcsc.org
The Arc of Coastal Carolina - Tel (803) 238-3040
The Arc of Pickens – Tel (864) 859-5416
NOFAS (National Organization on FAS)Phone: 202-785-4585 Web: www.nofas.org
Local Alcohol and Drug Treatment Resources: http://findtreatment.samhsa.gov/facilitylocatordoc.htm
Tools from www.cdc.gov/fasd
Elizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention
FASD Prevention Tool Kit
Developed by ACOG and CDC Contains
– Brief guide– Laminated screening
instrument– Resource information– Patient handouts
CME credits available
Information and Treatment Resources
National Organization on FAS (NOFAS)(202) 785-4585 www.nofas.org
Local Alcohol and Drug Treatment Resources http://findtreatment.samhsa.gov/facilitylocatordoc.htm
CDC FASD Home Page www.cdc.gov/fasd
Southeast Fetal Alcohol Spectrum Disorder Regional Training Center (FASD RTC) in the Meharry Medical College Department of Family & Community Medicine615) 327-5525www.familymedicine.mmc.edu www.fasdsoutheast.org
SC State Resources
Community Resources and Family Support Groups – Donna Martin, Parent – [email protected]– Forming a parent support group in South Carolina.
South Carolina Department of Disabilities and Special Needs– Phone: 803-898-9600 – Contact: Donna Windham, Director– www.state.sc.us/ddsn/ – Community Education Program. Prevention information, and
resources for developmental disabled persons and their families.
SC State Resources
Diagnosis of FAS Children's Hospital - Division of Developmental and
Behavioral Pediatrics– Phone: (864) 454-5115 – Contact: Desmond Kelly, M.D. – [email protected]
Greenwood Genetics Center– Phone: 864-941-8100 – Contact: Roger Stevenson, M.D.– [email protected] www.ggc.org
SC State Resources
Diagnosis of FAS University of South Carolina Medical School Developmental
Pediatrics– Phone: 803-935-5604 Fax: 803-935-5380 – Contact: Dr. Wuri– http://pediatrics.med.sc.edu/divisions/developmental_pediatrics.ht
m
Medical University of South Carolina - Department of Pediatric Neurology
– Phone: 843-792-3307 Fax: 843-792-3220 – Contact: Kenton Holden, M.D.– [email protected]– www.musc.edu
SC State Resources
Prevention Programs, including Treatment for Women – South Carolina Dept. of Alcohol and Other Drugs of Abuse
Services (DAODAS) Phone (803) 896-4198 Contact: Hanna Bonsu, Lead Coordinator
– South Carolina FAS Prevention Network Phone: 803-737-9138 Contact: Frankie Long, Coordinator
– The Prevention Center (SCADA) Phone: 803-778-2835 Contact: Glenn Peagler, M.Ed., CSPP, Director of Prevention, Patricia A. Colclough,
MS, CPP, Women's Issues Coordinator
SC State Resources
Protection and Advocacy for People with Disabilities, Inc.– Phone: 803-782-0639 – www.protectionandadvocacy-sc.org
Treatment Services for Affected Individuals – Growing Home
Phone: 803-791-5513 www.growinghome.org
– Medical University of South Carolina - Institute of Psychiatry Phone: 843-792-9888
FASDs are 100% preventable there is no known safe amount of alcohol
to drink while pregnant there is no safe time during pregnancy to
drink there is no safe type of alcohol
“Practice Makes Perfect”
for providers regarding screening and prevention
“Keep It Simple”
Vice Adm. Richard Carmona,
U.S. Surgeon General 2002-2006
“We must prevent all injury and illness that is preventable in society, and alcohol-related birth defects are completely preventable…”
“When a pregnant woman drinks alcohol, so does her baby. Therefore, it's in the child's best interest for a pregnant woman to simply not drink alcohol."
In Summary
Asses alcohol intake in pregnant and women in the child bearing age
Use brief intervention techniques to help pregnant women who consume alcohol
FASDs are 100% preventable—if a woman does not drink alcohol while she is pregnant
Early Recognition and multidisciplinary intervention of FASDs will decrease the impact