Introduction

to Diagnosis

and

PreventionRoger J. Zoorob, MD, MPH, FAAFPFrank S. Royal Sr. Professor and ChairDepartment of Family & Community Medicine Meharry Medical College

Fetal Alcohol Spectrum Disorders

Objectives

1. Give an overview of FASDsoutheast

RTC

2. Present diagnostic criteria for FAS

3. Review diagnostic criteria FASDs

4. Discuss screening and brief

intervention

FASD Southeast RTC

Washington

Montana

Oregon

Nevada

California

Utah

Arizona

New Mexico

Colorado

Idaho

Wyoming

North Dakota

South Dakota

Minnesota

IowaNebraska

Kansas

TexasFlorida

Mississippi

Louisiana

Alabama

Georgia

South Carolina

North Carolina

Virginia

Maine

New York

Michigan

Wisconsin

Oklahoma

Missouri

Arkansas

Tennessee

Kentucky

IllinoisIndiana

Michigan

Ohio

West Virginia

DC

Maryland

Delaware

New Jersey

Vermont

Rhode Island

Connecticut

New Hampshire

Massachusetts

Alaska

Hawaii

Pennsylvania

FASD Regional Training Centers 2011-2014

Arctic RTC, Univ of Alaska Anchorage

Midwestern RTC, Saint Louis Univ

Great Lakes RTC, Univ of Wisconsin

Southeastern RTC, Meharry Medical College

Frontier RTC, Univ of Nevada Reno

FASD Southeast RTC

FASD Southeast RTC

Covers the states of AL, FL, GA, KY, LA, MS, NC, SC, TN, TX, VT & U.S. Virgin Islands

FASD Southeast Structure 2011-2014

Meharry Medical College Nashville, TN

Sub-Awardee:Yasmin Senturias, MDUNC/Carolinas Medical Center Charlotte, NC

Muktar Aliyu, MD, DrPH Vanderbilt

Institue for Global HealthSusan Adams,

PhD, RN Vanderbilt University School of Nursing

Sam MacMaster,

PhD University of Tennessee

Rosalyn Pitt, PhD, PT

Tennessee State

University

FASD Southeast RTC

191103 401 444

187

1852,536

1,549

58

Southeast RTC Numbers Trained by State“All Activities” - Oct. 2008 – Sept. 2011

U.S. Virgin

Islands - 42

FASD Southeast RTC

Southeast RTC Numbers Trained by State

“All Activities” - Sept. 2011 – Sept. 2012

U.S. Virgin Islands -

224 9225 206 20

117

577318

28

146

FASD Southeast RTC

Fam

ily M

edicin

e

Nurse

s

Psyc

holo

gist

Social

Wor

k

Corre

ctio

nal H

ealth

Publ

ic H

ealth

0

20

40

60

80

100

120

8778

17

109

6760

Healthcare Professionals Trained Sept. 2011 – Sept. 2012

FASD Southeast RTC

Students TrainedSept. 2011 – Sept. 2012

Medical Nursing Social Work

OT/PT Public Health

Other0

50

100

150

200

250

300

350

400348

85 9780

15

73

FASD Southeast RTC

Residents TrainedSept. 2011 – Sept. 2012

Family Medicine Ob-Gyn Pediatrics0

20

40

60

80

100

120

140

64

43

118

FASD Southeast RTC

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

FASD Southeast RTC

Facial Abnormalities Of FAS

1. Smooth philtrum

2. Thin vermillion

3. Small palpebral fissures

Photo courtesy of Teresa Kellerman

FASD Southeast RTC

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 from

http://depts.washington.edu/fasdpn/htmls/order-forms.htm

http://fasdcenter.samhsa.gov/educationTraining/courses/CapCurriculum/competency2/facial2.cfm

FASD Southeast RTC

Palpebral Fissure Measurement

www.fasdpn.org

FASD Southeast RTC

Palpebral Fissure Length endocanthion to exocanthion

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. 

FASD Southeast RTC

#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)

FASD Southeast RTC

#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

FASD Southeast RTC

#3 CNS Abnormalities of FAS2. Neurologic Abnormality

• Motor problems or seizure NOT from a postnatal insult or fever

• Other soft neurologic signs outside normal limits

3. 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 functioningAbstract concepts Problem solvingMotor functioning Attention

problems/hyperactivity Social skills Other (sensory, memory, language)

Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005/54;1-10

FASD Southeast RTC

What are FASDs?

“Fetal Alcohol Spectrum

Disorders” 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

FASD Southeast RTC

From FAS Diagnostic Criteria to Life with an FASD…

• IQ averages 60, range 20 -110• Poor Judgment• Problems with

o Behavioro Motor Skillso Social Interactionso Excessive body contacto Impulsivenesso Intrusivenesso Lack of stranger anxiety

www.cdc.gov/ncbddd/fasd/videos/Iyal/long/Iyal_long.html

FASD Southeast RTC

Beyond Early Childhood

Difficulties Socializing

• Maintaining Friendships

• Depression and Anxiety

• Inappropriate Sexuality

FASD Southeast RTC

…. 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

GOAL Independent Living

FASD Southeast RTC

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)

FASD Southeast RTC

Stomach

Brain

Liver

Kidneys

Fetus

Muscles

Nerves

Placenta

Brain

Heart

Organs

Breast

No known safe amount of alcohol to drink while pregnant

FASD Southeast RTC

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, 24% reported any

alcohol use and 6% 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

FASD Southeast RTC

Alcohol Assessment and Intervention in Primary Care

AskAssess Advise Assist

Alcohol AssessmentKnow what a Standard Drink is?

FASD Southeast RTC

At-Risk Drinking!

FASD Southeast RTC

Gender/Time Per Week Per Occasion

Men > 14 drinks > 4 drinks

Women > 7 drinks > 3 drinks

Seniors > 7 drinks > 1 drink

Alcohol AssessmentFrequency 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?

FASD Southeast RTC

FASD Southeast RTC

FASD Southeast RTC

FASD Southeast RTC

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.”

FASD Southeast RTC

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 Research on Minority Health, Identification of At-Risk

Drinking and Intervention with Women of Childbearing Age. NIH Publication No. 99-4368 (Printed 1999)

FASD Southeast RTC

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.

FASD Southeast RTC

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

FASD Southeast RTC

?QUESTIONS?

Thank you!

FASD Southeast RTC