Feb 2, 2017 Wissick 1 The Basics of FASD Awareness and Prevention Cheryl A. Wissick, Ph.D. Trainer, SC FASD Collaborative Presentation adapted from information from Dan Dubovsky, FASD Specialist, FASD CFE, SAMHSA Roger Zoorob, M.D., Meharry Medical College, Dr. Sandra Kelly, USC & Diane Malbin, FASCETS FASD • Fetal Alcohol Spectrum Disorders is not a diagnostic category, but rather an umbrella term describing the effects that can occur in a person whose mother drank alcohol during pregnancy. • These effects may include physical, mental, behavioral and/or learning disabilities but a RANGE of manifestations. Prevalence FASD • FAS in this community likely ranges from 6 to 9 per 1000 children (midpoint, 7.5) • PFAS from 11 to 17 per 1000 children (midpoint, 14) • Total rate of FASD is estimated at 24 to 48 per 1000 children. or 2.4% to 4.8% (midpoint, 3.6%) (1 in 50 to 1 in 20). • Cost of Diagnostic services for FASD in Canada $5.0 to $7.3 million per year. • May, et. al. (2014) Prevalence and Characteristics of Fetal Alcohol Spectrum Disorders, Pediatrics Popova S, Lange S, Burd L, Chudley AE, Clarren SK, Rehm J (2013) Cost of Fetal Alcohol Spectrum Disorder Diagnosis in Canada.
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Feb2,2017
Wissick 1
The Basics of FASD Awareness and
Prevention CherylA.Wissick,Ph.D.
Trainer,SCFASDCollaborative
PresentationadaptedfrominformationfromDanDubovsky,FASDSpecialist,FASDCFE,SAMHSA
RogerZoorob,M.D.,MeharryMedicalCollege,Dr.SandraKelly,USC&DianeMalbin,FASCETS
FASD
• FetalAlcoholSpectrumDisordersisnotadiagnosticcategory,butratheranumbrellatermdescribingtheeffectsthatcanoccurinapersonwhosemotherdrankalcoholduringpregnancy.
• Theseeffectsmayincludephysical,mental,behavioraland/orlearningdisabilitiesbutaRANGEofmanifestations.
PrevalenceFASD• FASinthiscommunitylikelyrangesfrom6to9per1000children(midpoint,7.5)
• PFASfrom11to17per1000children(midpoint,14)• TotalrateofFASDisestimatedat24to48per1000children.or2.4%to4.8%(midpoint,3.6%)(1in50to1in20).
• CostofDiagnosticservicesforFASDinCanada$5.0to$7.3millionperyear.
• May,et.al.(2014)PrevalenceandCharacteristicsofFetalAlcoholSpectrumDisorders,Pediatrics
PopovaS,LangeS,BurdL,ChudleyAE,ClarrenSK,RehmJ(2013)CostofFetalAlcoholSpectrumDisorderDiagnosisinCanada.
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• AlcoholEffectsfirstrecognizedin1968
• FetalAlcoholSyndromedefinedin1973
• FetalAlcoholEffectsdefinedin1978butChangedtoARND-AlcoholRelatedNeurodevelopmentalDisorder
• 100%preventableand0%curable
4Syndromes• FetalAlcoholSyndrome(FAS)• PartialFAS(PFAS)• Alcohol-RelatedNeurodevelopmentalDisorders(ARND)
• Alcohol-RelatedBirthDefects(ARBD)
DSM-5:315.8,2013(F88)Neurodevelopmentaldisorderassociatedwithprenatalalcoholexposure3areasofdeficit:neurocognitive,self-regulationandAdaptiveFunctioning
FASDintheICD-10-CM
Dubovsky,2017
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FAS• Facialdysmorphia:smallpalpebralfissures(10th%ileorbelow),smoothphiltrum*,thinvermilionborder*
• Growthdeficiencies:weight/length-atorbelowthe10thpercentile(anymeasurementfrombirthtopresenttime)
• CNSAbnormality:Structural,NeurologicalorFunctional
• (+)/(-)Maternalalcoholuseinpregnancy(historyisnotalwaysavailable)
• CDCGuidelinesforReferralandDiagnosis,2004 (*Rank4or5onUnivofWashingtonLip-PhiltrumGuide)
FASSource:www.fasdpn.org
CNSAbnormality• Structural
• Headcircumferenceatorbelow10thpercentile• Clinicallysignificantabnormalitiesonneuroimaging
• Neurological• Seizures• Focaldeficits
• Functional• Cognitive/developmentaldeficitsordiscrepancies• Executivefunctioningdeficits• Motorfunctioningdelays• Problemswithattentionorhyperactivity• Problemswithsocialskills• Others:Sensoryproblems,pragmaticlanguage
problems,memorydeficits,etc.
FASvs.FASD• Fullfacialeffectsareonlyrequiredforadiagnosisifonecannotsubstantiatethatthemotherdrankduringpregnancy.
• FAShasfacialfeatures,growthdeficitandCNSabnormality
• EarlydiagnosisofFASDbeforeage6canreducesecondarycharacteristics
• HavingfullFASandalowerIQincreaselikelihoodofearlydiagnosis&intervention.
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HigherriskfactorsFASD
• Typicallynofacialfeatures• IQabove70-only25%haveanintellectualdisabilityorIQbelow70
• Higherscoresonmaladaptivebehavior• Lesschanceforidentificationasitrequiresmother’sself-reportofdrinkingduringpregnancy.
IsFASDNeurobehavioral?
• AlcoholcausesBrainDamagebykillingcells• Alcoholaffectsstructureandfunctionofthebrain
• BehaviorsaresymptomsNOTdisorder• Behaviorisnotwillfulorpurposefulbutduetodamagedbrain
• Therefore:INVISIBLE,PHYSICALDISABILITYWITHBEHAVIORALSYMPTOMS
HistoricalPerspective• 1970’s–StudiesonFASD&animalmodelsofFASDfocusingonprovingthatalcoholwastheculprit(ateratogen).
• 1981–SurgeonGeneralReportwarningagainstdrinkingwhilepregnant
• 1980’sand1990’s–researchfocusedondescribingtheeffectsofalcohol• Regionsvulnerable,patternsandtiming
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PatternsandTimingofalcoholexposure
• 1stTrimester:Alcoholinterfereswithorganizationofbraincells,FacialFeatures-3rdto4thwk
• 2ndTrimester:AlcoholcausesclinicalfeaturesofFAS
• 3rdTrimester:Alcoholleadstoproblemsencodingvisual&auditoryinformation
CurrentResearchFocus• 2000’stopresent:Relatingspecificbrainregionstobehavioraldeficitsandfocusontreatmentandprevention
• AlcoholinhibitscriticalL1celladhesionfromthebrain&spinalcord–braindamage
• Certaincompoundscanblockalcohol’sinhibition• CholineandFolatesupplements• SimilardrugsasthoseusedtotreatAlzheimer’s
Howmuchalcoholdependson• Abilitytometabolizealcohol(genetics,liver)• Dosingofalcohol• Patternandtimingofexposure• MotherandInfantsgenetics• Generalhealthandnutrition• Levelofstressand/ortrauma• OlderAgeandNumberofbirthsmotherhashad
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WhataboutDad?• Alcoholconsumptionaffectsgenesinspermwhichareresponsiblefornormalfetaldevelopment.
• Thefather’slifestyleandhissupportofthemotherarealwaysimportantpriortoandduringpregnancybecausehecanhaveasignificantinfluenceonthemother’schoicesandherphysicalandbehavioralhealth.
• EpigenticComponentslongrangechangestoDNAHyeJeongLee,Jae-SungRyu,NaYoungChoi,YoSephPark,YongIlKim,DongWookHan,KisungKo,ChanYoungShin,HanSungHwang,Kyung-SunKang,KinarmKo.Transgenerationaleffectsofpaternalalcoholexposureinmouseoffspring.AnimalCellsandSystems,2013;17(6):429DOI:10.1080/19768354.2013.865675
Dadisimportanttoo..
• “Upto75percentofchildrenwithFASDhavebiologicalfatherswhoarealcoholics,suggestingthatpre-conceptualpaternalalcoholconsumptionnegativelyimpactstheiroffspring.”
Day,Savani,Krempley,Nguye,Kitlinska(2016).Influenceofpaternalpreconceptionexposuresontheiroffspring:ThroughepigeneticstophenotypeAmericanJournalofStemCells5(1):11-18
PrevalenceofAlcoholUse
From:www.cdc.gov/ncbddd/fasd/data.html
14%ofAmericanshaveAlcoholUseDisorder(AUD),DSM-5
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PrevalenceofAnyAlcoholUseamongWomenAged18-44Years–UnitedStates,1991-2005
• High-risk drinking among women has not declined in the past decade
0
10
20
30
40
50
60
1991
19
92
1993
19
94
1995
19
96
1997
19
98
1999
20
00
2001
20
02
2003
20
04
2005
Prev
alen
ce (%
)
Not pregnant Pregnant
BehavioralRiskFactorSurveillanceSystem,1991-2005,UnitedStates
1EpisodeofBingeDrinking…
Binge:definedbytheCDCasfourormoredrinksinaboutatwo-hourperiod
2012research-evensmallamountsofalcoholcanlowerbabyIQ
BingeDrinking
0
5
10
15
20
25
30
18–24
25–34
35–44
45–64
≥65
White,non-H
ispanic
Black,non-Hispanic
Hispanic
Other,n
on-Hispanic**
Lessthanhighschooldip
loma
Highschooldip
loma
Some
college
Collegegraduate
<$25,00
0
$25,000–$49,99
9
$50,0
00–$74,99
9
≥$75,00
0
BingeDrinkingPrevalence%
Age Ethnicity Education Income
2012,anestimated855,000adolescentsages12–17hadanAUD
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Drinkingattimeofconception
• IconsumedalcoholbeforeIknewIwaspregnant,ismybabyok?
• Theory:Beforethefirstmissedperiod(0-18daysofconception)thereisnaturalprotectionfromanteratogenicagentbecausethezygoteisself-contained,anyalcoholinthebloodstreamofthemotherwillnotimpacttheembryobeforetheplacentaisformedanddeliveringnutrientstotheembryo.
• However,ifyouaretryingtogetpregnantSTOPdrinking
AtriskforAlcoholExposedBirths
• 3.3millionUSwomen,ages15-44,wereatriskofexposingtheirdevelopingbabytoalcoholiftheyweretobecomepregnant.
• 3in4womenwhowanttogetpregnantdonotstopdrinkingalcoholwhentheystopusingbirthcontrol.
• WealthierAmericansarealsolessworriedthaneveryoneelseaboutpregnantwomendrinking.
• CDC,VitalSigns,Feb,2016
FromChoicesfactsheetUnderstandingRiskforAlcohol-ExposedPregnancies(AEPs)
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FASD-collectDiagnoses• Reactiveattachmentdisorder• ADHD• Oppositionaldefiant• BiPolarDisorderNOS• CognitiveDisorderNOS• DepressiveDisorderNOS• PersonalityDisorder,MixedwithBorderlineAntisocialandSchizotypalfeatures
• ConductDisorder,DisruptiveBehavior
ConsiderFASDastheumbrella
RememberthebehaviorsareONLYthesymptomsofunderlyingphysicaldisorder
AvailabletoolsforPrevention• CHOICES-CDCfundedprogramfornon-pregnantwomenatrisk
• ScreeningandBriefIntervention• Parent-ChildAssistanceProgram–a3yearcasemanagementmodel
• ACOGToolkit• AmericanAcademyofPediatricstoolkit• AssociationofReproductiveHealthProfessionals
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ScreeningforCaregivers• Importantfortailoringtreatmentandfutureprevention
• Arelabeledasneglectful,uncaringorsabotaging
• Mightenduprepeatingbehaviors–multiplepregnancies
• Havechildrenremovedfromtheircare• Failtofollowthrough--multipledirections• Loseparentalrights
Visitscfasd.weebly.com
Manyguidestodownload
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ToolsforTrainingstudents
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