Fetal Alcohol Exposure and Fetal Alcohol Syndrome

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1 Fetal Alcohol Exposure and Fetal Alcohol Syndrome

2 Dana E. Johnson, M.D., Ph.D. Professor of Pediatrics Divisions of Neonatology and Global Pediatrics University of Minnesota

3 This presentation is made possible, in part, by the support of the American people through the United States Agency for International Development (USAID). The content of this presentation is the sole responsibility of the author(s) and does not necessarily reflect the views of USAID or the United States Government. The opinions and views expressed by the authors in this document do not necessarily reflect the views and opinions of KPMG.

5 Is FASD a New Problem? Behold, thou shalt conceive and bear a son and now drink no wine or strong drink Judges 13:7 Aristotle said, Foolish, drunken, and hare-brained women most often bring forth children like unto themselves, morose and languid.

6 What is FASD? Fetal Alcohol Spectrum Disorders a set of physical, behavioral, and cognitive disorders seen in individuals exposed to alcohol prenatally Lifetime disability with brain injury that never goes away Broad range (spectrum) of characteristics that vary from person to person

7 Facts about Fetal Alcohol Spectrum Disorders (FASD) FASD is the #1 cause of mental retardation in North America Most people with FASD have average IQs Rate of FAS (Syndrome) is 1:500 births Rate of FASD (spectrum) is 1:100 births FASD is 100% preventable

8 On any given day in the United States 10,500 babies are born: 1 of these babies is HIV positive 3 of these babies are born with Muscular Dystrophy 7 of these babies are born with Spina Bifida 12 of these babies are born with Down Syndrome 40 of these babies are born with Autism Spectrum Disorder 100 of these babies are born with FASD!

9 Of all the substances of abuse including cocaine, heroin, and marijuana, alcohol produces by far the most serious neurobehavioral effects in the fetus resulting in life-long permanent disorders of memory function, impulse control and judgment. IOM Report to Congress, 1996

10 Reported Alcohol/Drug Exposure in Institutionalized Children Adopted to the US

11 Diagnosis of Fetal Alcohol Syndrome Growth Failure Brain Damage Facial Features Maternal Alcohol Consumption

12 Diagnosis of Fetal Alcohol Syndrome Growth Failure 25% Brain Damage 24% Facial Features Maternal Alcohol Consumption 28%

13 Effects of Orphanage Life vs. Effects of Alcohol Beer FAS Orphanage Growth Failure X X Neurological Problems X X Hyperactivity X X Distractibility X X Retardation X X Poor Social Skills X X Behavior Problems X X Speech Delays X X Congenital Anomalies X X Facial Dysmorphology X

14 Face of FAS forms during the 3 rd week of gestation, most likely days 19-21

15 Facial Features

17 Prevalence of Face 3-4 in Eastern European Adoptees University of Minnesota IAC n=222, No Face 3-4 Diagnosed From Other Regions (n=261) %

18 Results Pre-Adoption History 62.5 % Face 1,2 Face 3,4 50 % 12.2 % 20.4 % % of Children Removed from Home by the Government Record of Maternal Alcohol Use

Height Weight OFC Weight by Height * * * Initial *

19 Physical Growth Initial and 6 Months Post-Adoption Assessments Height Weight OFC Weight by Height Height Weight OFC Weight by Height * * * Initial * * * 6 Months * Significant at p<.05 Face 1, 2 Face 3, 4

20 The FASD Umbrella Alcohol Related Neurological Defects (ARND) Fetal Alcohol Effects (FAE) Alcohol Related Birth Defects (ARBD) Partial Fetal Alcohol Syndrome (pfas) Fetal Alcohol Syndrome (FAS)

21 Brain and Eyes Develop Throughout Gestation

22 Vision Problems in Children with Fetal Alcohol Syndrome (n=25) 96% Abnormal Ocular Findings Optic Nerve Hypoplasia 76% Strabismus 52% (2%) Visual Acuity 20/70 68% Unchanged 59% Improved 41% Other problems (Microphthalmos, buphthalmos, phthisis, microcornea, coloboma, blepharoptosis, IAP 26% in Alcohol/Drug Exposed Children vs. 14% cataract, persistent hyperplastic primary vitreous and nystagmus) Stromland and Hellstrom, Pediatrics 1996:97:845-50

23 Newborn Brain

Most Affected Areas of the Brain Frontal Lobes Executive functions, impulse control, judgment Cerebellum Coordination, movement, behavior and memory Corpus Collosum

24 Most Affected Areas of the Brain Frontal Lobes Executive functions, impulse control, judgment Cerebellum Coordination, movement, behavior and memory Corpus Collosum Transfer of information from one hemisphere to the other Basal Ganglia Processes memory, time perception, setting goals, predicting outcomes Hippocampus Learning and memory

25 Effects of Orphanage Life vs. Effects of Alcohol Beer FAS Orphanage Growth Failure X X Neurological Problems X X Hyperactivity X X Distractibility X X Retardation X X Poor Social Skills X X Behavior Problems X X Speech Delays X X Congenital Anomalies X X Facial Dysmorphology X

26 Frontal Lobe Controls impulses Emotional response EXECUTIVE FUNCTIONS Linking 2 or more ideas together Understanding abstract or complex concepts Generalizing (ex. Learning to cross street) Understanding cause & effect / consequences Judgment

27 Cerebellum Movement, motor control Balance & equilibrium Muscle tone Ability to judge distances Involved in some cognitive processes such as attention

28 Basal Ganglia Can affect spatial memory and behaviors like perseveration and inability to switch modes, work towards goals, and predict behavioral outcomes Time perception

29 Hippocampus Connects sensory input to motor output Damage interferes with sensory information and connecting that information to a motor activity Navigation (Taxi drivers have bigger hippocampi) Learning and memory problems For example, take a note to school but not remember what to do with it

30 Hypothalamus / Brain Stem Receives input from all over the body and sends it to the cerebral cortex Controls appetite, emotions, temperature, pain sensation Organizes behavior related to survival-fighting, fleeing, feeding Ability to sleep is a brain stem function

31 Parietal Lobe Damage to this part of the brain can cause: Difficulty with math Problems distinguishing left from right Difficulties with hand / eye coordination Problems with touch perception

Brain from Above Right Side judging the position of things in space knowing body position understanding and remembering things we do and see putting bits of information together to make an entire

32 Brain from Above Right Side judging the position of things in space knowing body position understanding and remembering things we do and see putting bits of information together to make an entire picture Impulses, Creativity Left Side understanding and use of language (listening, reading, speaking and writing) memory for spoken and written messages detailed analysis of information Facts, Rules, Order

FAS and the Brain A B C A B C A. Magnetic resonance imaging showing the side view of a 14-year-old control subject with a normal corpus callosum; B. 12-year-old with FAS and a thin corpus callosum; C.

33 FAS and the Brain A B C A B C A. Magnetic resonance imaging showing the side view of a 14-year-old control subject with a normal corpus callosum; B. 12-year-old with FAS and a thin corpus callosum; C. 14-yearold with FAS and agenesis (absence due to abnormal development) of the corpus callosum. Source: Mattson, S.N.; Jernigan, T.L.; and Riley, E.P MRI and prenatal alcohol exposure: Images provide insight into FAS. Alcohol Health & Research World 18(1):49 52.

34 FAS and the Brain These two images are of the brain of a 9-year-old girl with FAS. She has agenesis of the corpus callosum, and the large dark area in the back of her brain above the cerebellum is essentially empty space. Source: Mattson, S.N.; Jernigan, T.L.; and Riley, E.P MRI and prenatal alcohol exposure: Images provide insight into FAS. Alcohol Health & Research World 18(1):49 52.

35 FASD is the Invisible Disability Attention deficits Memory deficits Hyperactivity Difficulty with abstract concepts Inability to manage money Poor problem solving skills Difficulty learning from consequences Immature social behavior Inappropriately friendly to strangers Lack of control over emotions Poor impulse control Poor judgment

36 Parent Reported Problems and Risk Factors Parent-Reported Problem Age Orph. Dep LBW Alcohol/ Drug Speech/Language Delay ns Developmental Delay ns Autistic Behavior ns ns 3.65 ns Sensory Processing Problems ns ns 5.12 Attachment Disorder 1.08 ns 3.30 ns 2.26 ADD/ADHD ns ns 2.45 ns 3.95 Learning Problems ns ns 2.18 ns 4.60 Cognitive Impairment ns ns School Failure ns ns ns ns 5.29

37 CBCL Internalizing Scores and Risk Factors CBCL Scale Age Orph. Dep LBW Alcohol/ Drug Withdrawn Behavior ns ns Somatic Problems ns ns 1.83 ns ns Anxiety ns ns ns ns 2.29 Social Problems ns ns 2.25 ns 3.26 Internalizing Problems ns ns 2.12

38 CBCL Externalizing Scores and Risk Factors CBCL Scale Age Orph. Dep LBW Alcohol/ Drug Attention Problems ns ns 2.67 ns 3.44 Delinquency ns ns ns ns 2.89 Aggression ns ns ns ns 2.39 Sex Problems ns ns 1.62 ns ns Externalizing Problems ns ns ns ns 2.41 Total Problems ns ns 2.89 ns 3.83

39 Secondary Disabilities Primary disabilities are those the child is born with. Secondary disabilities are those that develop as a result of failure to properly deal with the primary disabilities.

40 Secondary Disabilities Mental Health Problems Truancy at school Trouble with the Law Inappropriate Sexual Behavior Alcohol / Drug Problems Pregnancy

41 Secondary Disabilities by Diagnosis

42 Secondary Disabilities by IQ

43 Protective Factors A diagnosis before 6 years of age Living in a stable, nurturing home Not being a victim of violence Having received developmental disabilities services Having a diagnosis of FAS rather than FAE Lower than 70 IQ

44 Positive Characteristics Friendly, cuddly, happy Caring, kind and loyal Curious and involved Energetic, hard working Fair and cooperative Artistic or musical Highly verbal Long term visual memory

American Academy of Pediatrics 2014 Educational Webinar Series Monday, July 28, 3:00 3:30 pm ET

American Academy of Pediatrics 2014 Educational Webinar Series Monday, July 28, 3:00 3:30 pm ET FETAL ALCOHOL SPECTRUM DISORDERS (FASDS): DETECTION, DISCOVERY, AND DIAGNOSIS PRESENTED BY YASMIN SENTURIAS,