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ATTC Center of Excellence on Behavioral Health for Pregnant and Postpartum Women and Their Families

ATTC Regional Center Partners:Great Lakes ATTCMid-America ATTCNew England ATTCSoutheast ATTC

Purpose: The Center was established to develop a family-centered national curricula, web-based toolkit, and provide support for national training and resource dissemination.

Understanding Fetal Alcohol Spectrum Disorders (FASD): Implications for Women’s Treatment

Georgiana Wilton, PhDUniversity of Wisconsin-Madison

School of Medicine and Public HealthDepartment of Family Medicine and Community Health

CoE PPW Webinette 1January 12, 2016

Webinette Overview

• Fetal Alcohol Spectrum Disorders (FASD) in a Nutshell

• Implications for Women’s Treatment Programs

Alcohol’s Potential Effect on Pregnancy

Prenatal Development Flickr.com/2013

Severity of Effects

Severity of effects depends on:

• dose • pattern • timing

What is Fetal Alcohol Syndrome (FAS)?

Fetal Alcohol Syndrome

A specific, yet variable, combination of abnormalities seen in some individuals who were exposed to high levels of alcohol during gestation.

Major signs leading to a diagnosis of FAS

• Central Nervous System effects

• Small size and weight

• Specific facial features

Fetal Alcohol Spectrum Disorders (FASD)

• An umbrella term used to describe the range of effects that can occur in individuals who were prenatally exposed to alcohol

• Effects may be physical, mental, behavioral and or learning disabilities

• NOT intended as a clinical diagnosis

FASD Center for Excellence

Diagnoses under the Umbrella

• Fetal Alcohol Syndrome (FAS)

• Partial FAS (pFAS)

• Alcohol-related neurodevelopmental disorder (ARND)

• Alcohol-related birth defects (ARBD)

DSM-5

Section II

Neurodevelopmental disorder associated with prenatal alcohol exposure (p. 86)

315.8 (F88)

Section III: Conditions for Further Study

Neurobehavioral disorder associated with prenatal alcohol exposure (p. 798)

Podcast: The Clinical Exam

https://www.youtube.com/watch?v=044Zxy3_0u8

Podcast: Foundations of FASD

https://www.youtube.com/watch?v=ARPgT26dg24

Fetal Alcohol Syndrome

.2-1.5 per 1,000 live birthsMay & Gossage, 2001Review of data from multiple surveillance studies

6 to 9 per 1,000 first gradersMay et al., 2014Screened 70.5% of all first graders with <25% height/weight/head circumference

Fetal Alcohol Spectrum Disorders

24 to 48 per 1,000 children2.4-4.8%

May et al., 2014

Specific High Risk Populations

Juvenile Justice

1% FAS

22.3% FAE (old term)

Fast et al., 1999

Screened 287 youth remanded for forensic psychiatric evaluation (in system >1 year)

Specific High Risk Populations, cont.

Children in Foster Care10-15 per 1,000 children

10-15x greater than general population (their assertion)Astley et al., 2002

Adult women in AODA Treatment Programs

22 outreach clinics conducted over 5 years76 referrals of adult women at risk34% diagnosed with one of FASDs

Wisconsin FASD Treatment Outreach Project

Cautions

Methodology varies across studies

Populations are highly selected/screened

Criteria for FASDs may vary

Review of Brain Structures/Functions

http://www.headwaywearside.org.uk/about.html23

Implications of PAE

Sensory or regulatory effects

Developmental delays

Deficits in neurocognitive functioningAcross all domains

• Visual/spatial abilities• Math skills• Visual-motor integration

Drawing/writing

Hyperactivity/Distractibility

Memory deficits

Implications of PAE, cont.

• ADHD/Impulsivity

• Difficulty with executive functioning/abstracting abilities

• Poor comprehension of social rules, expectations, boundaries

• Easily influenced by others

• Difficulty predicting or understanding consequences of behavior

• Concrete thinkers

• Mental health issues

Also consider…

Genetics of biological parents

• Including mental health disorders

Environment

• Second-hand exposures

• Trauma

Implications for Treatment and Recovery

FASD & Other Cognitive Disabilities in Treatment Settings

Disabilities are common in the U.S.

“Hidden” conditions may affect up to 40% of clients in treatment programs

Individuals with disabilities are less likely to complete treatment

Helwig & Holicky, 1994

Think in terms of hidden disabilities when discussing routine subjects:

Example: Incorporate follow-up questions when discussing medical history, success in school, participation in other social service programs

• Did you ever have special classes or tutoring in school?

• Have you ever had problems…?Concentrating? Getting your point across?

FASD & Other Cognitive Disabilities in Treatment Settings

Functional limitations can interfere with treatment progress

Don’t assume:

• Lack of progress = lack of motivation

• Not following directions = noncompliant

• Lack of concentration = ambivalence

• Inability to recognize negative consequences = denial

Sometimes the biggest barrier is our attitude…

FASD & Other Cognitive Disabilities in Treatment Settings

Recommendations

• Screen women for FASD during intake

• Conduct adaptive functioning assessment

• If warranted, refer for diagnostic assessment

• Modify treatment plan based on individual characteristics

Meet a woman where she’s at!

Screening

• Use (or develop) screening tool for consistent use

• Use collateral information as needed

• Consider family history in screening

Do parents have cognitive/mental health concerns?

Screening for FASDs

Conduct Adaptive Functioning Assessment

Consider:• Vineland Adaptive Behavior Scales-II

• Good evidence base with FASD

Adaptive functioning data provides:

• How women navigate their environment can bring challenges to light

• Starting point for treatment planning

Collect Additional Information

Medical records

School records

Observation

Formalized assessment of:

• Executive function

• Intellectual capacity

• Sensory processing function

Refer for Diagnostic Assessment

Screening does not mean diagnosing

• Suspicions do not equal a diagnosis

Refer to experts for assessment, diagnosis

National Resource Directory: www.nofas.org

Few physicians are comfortable/trained to diagnose FASDs in adults!

What Conditions should be Considered?

Fetal Alcohol Spectrum DisordersHistory may be more important than physical features

Learning Disabilities/Mental RetardationBacked up by school/psych records

Traumatic Brain InjuryAccident/violence-induced

Korsakoff’s SyndromeWatch for sudden onset of memory problems

Co-Occurring Mental Health Issues

References to review:

• Treatment Improvement Protocol (TIP) #58

• Grant et al., 2013: The Impact of Prenatal Alcohol Exposure on Addiction Treatment (J Addict Med, Vol 7, No 2)

Addressing the Needs of Clients with FASDs

Strategies for Working with Women in Treatment

• Environmental

• Counseling/Therapy

• Educational

• Physical Health/Medical

Environmental

• Structure

• Predictability

• Monitored level of stimulation

Counseling/Therapy, cont.

Modify counseling to accommodate cognitive disability:

• Individual vs. group counseling

• Plan session times• Time of day

• Length of session

• Number of sessions per week

• Consider insight of client vs. actual behavior

• Concrete vs. insight-oriented counseling

Educational

• Accommodate information processing, comprehension and retention deficits

• Multi-modality instruction

• Use concrete, practical language

• Appropriate reinforcement techniques

• Repetition

Physical Health/Medical

Behavior may be related to (or exacerbated by) other health issues.

Consider:

• Sleep disorders

• Sensory processing disorders

• Exercise

• Diet

• Medication

CAUTION: What to Watch For

Don’t assume if a client can repeat rules that she understands them and is capable of following them

• Information processing

• Expressive vs. Receptive language

• “Masking”

(i.e., waiting for others to go first)

• Clue gathering

For More Information

Georgiana Wilton, PhD

University of Wisconsin School of Medicine and Public Health

Department of Family Medicine and Community Health

1100 Delaplaine Court

Madison, WI 53715

Phone: 608-261-1419

Fax: 608-263-5813

Georgiana.Wilton@fammed.wisc.edu

References

• Bailey, B. A. & Sokol, R. J. (2011). Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. Alcohol Research & Health, 86-91.

• Bremner, J. D. (1999). The lasting effects of psychological trauma on memory and the hippocampus.

• Burd, L., Klug, M. G., Martsolf, J. T., & Kerbeshian, J. (2003). Fetal alcohol syndrome: Neuropsychiatric phenomics. Neurotoxicology and Teratology, 25, 697-705.

• Burden, M. J., Westerlund, A., Muckle, G., Dodge, N., Dewailly, E., Nelson, C. A., Jacobson, S. W., Jacobson, J. L. (2011). The effects of maternal binge drinking during pregnancy on neural correlates of response inhibition and memory in childhood. Alcoholism: Clinical and Experimental Research, 35, 69-82.

References• CDC. (2008). The Effects of Childhood Stress on Health Across the

Lifespan. www.cdc.gov

• CDC. (2009). FASD Competency-Based Curriculum Development Guide for Medical and Allied Health Education and Practice. www.cdc.gov

• Chen, W. A. & Maier, S. E. (2011). Combination drug use and risk for fetal harm. Alcohol Research & Health, 34, 27-28.

• Coles, C. (2011). Discriminating the effects of prenatal alcohol exposure from other behavioral and learning disorders. Alcohol Research & Health, 34, 42-50.

• Crocker, N., Vaurio, L., Riley, E. P., & Mattson, S. N. (2011). Comparison of verbal learning and memory in children with heavy prenatal alcohol exposure or attention-deficit/hyperactivity disorder. Alcoholism: Clinical and Experimental Research, 35, 1114-1121.

• De-Bellis, M. D., Lefter, L., Trickett, P. K., & Putnam, F. W. (1994). Urinary catecholamine excretion in sexually abused girls. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 320-27.

• Dold, L. (1998). Substance Abuse and Treatment Needs Among Pregnant Women in Wisconsin. A report to the Wisconsin Department of Health and Family Services. Wisconsin Survey Research Laboratory, University of Wisconsin-Extension, Madison.

• Ewing, S. W., Filbey, F. M., Sabbineni, A., Chandler, L. D., & Hutchison, K. E. (2011). How psychosocial alcohol interventions work: A preliminary look at what fMRI can tell us. Alcoholism: Clinical and Experimental Research, 35, 643-651.

References

References

• Feldman, H. S., Jones, K., L., Lindsay, S., Slymen, D., Klonoff-Cohen, H., Kao, K., Rao, S. & Chambers, C. (2011). Patterns of prenatal alcohol exposure and associated non-characteristic minor structural malformations: A prospective study. American Journal of Medical Genetics Part A, 155, 2949-2955.

• Feldman, H. S., Jones, K. L., Lindsay, S., Slymen, D., Klonoff-Cohen, H., Kao, K., Rao, S. & Chambers, C. (2012). Prenatal alcohol exposure patterns and alcohol-related birth defects and growth deficiencies: A prospective study. Alcoholism: Clinical and Experimental Research, doi:10.1111/j.1530-0277.2011.01664.x

• Gaensbauer, T. J. (1995). Trauma in the preverbal period: Symptoms, memories, and developmental impact. Psychoanalytic Study of the Child, 50, 122-49.

• Green, J. H. (2007). Fetal alcohol spectrum disorders: Understanding the Effects of Prenatal Alcohol Exposure and Supporting Students. Journal of School Health, 77, 103-108.

• Idrus, N. M. & Thomas, J. D. (2011). Fetal alcohol spectrum disorders: Experimental treatments and strategies for intervention. Alcohol Research & Health, 34, 76-85.

• Jacobson, J. L., Dodge, N. C., Burden, M. J., Klorman, R., & Jacobson, S. W. (2011). Number processing in adolescents with prenatal alcohol exposure and ADHD: Differences in the neurobehavioral phenotype. Alcoholism: Clinical and Experimental Research, 35, 431-442.

References

• Kully-Martens, K., Denys, K., Treit, S., Tamana, S. & Rasmussen, C. (2011). A review of social skills deficits in individuals with fetal alcohol spectrum disorders and prenatal alcohol exposure: Profiles, mechanisms, and interventions. Alcoholism: Clinical and Experimental Research, doi:10.1111/j.1530-0277.2011.01661.x

• LaDue, R. A., Schacht, R. M., Tanner-Halverson, P., McGowan, M. (1999). Fetal Alcohol Syndrome: A Training Manual to Aid in Vocational Rehabilitation and Other Non-Medical Services. Northern Arizona University Institute for Human Development, Project Number RD-29.

References

References

• Mattson, S. N., & Riley, E. P. (2011). The quest for a neurobehavioral profile of heavy prenatal alcohol exposure. (2011). Alcohol Research & Health, 34, 51-55.

• Mattson, S. N., Schoenfeld, A. M., & Riles, E. P. (2001). Teratogenic effects of alcohol on brain and behavior. Alcohol Research and Health, 25, 185-191.

• May, P. A. & Gossage, J. P. (2011). Maternal risk factors for fetal alcohol spectrum disorders. Alcohol Research & Health, 34, 15-26.

References

• Paley, B. & O’Connor, M. J. (2011). Behavioral interventions for children and adolescents with fetal alcohol spectrum disorders. Alcohol Research & Health, 34, 64-75.

• Phelps, L. (2005). Fetal Alcohol Syndrome: Neuropsychological Outcomes, Psychoeducational Implications, and Prevention Models. In R. D’Amato, E. Fletcher-Janzen, & C. Reynolds (Eds.), Handbook of School Neuropsychology. Hoboken, NJ: John Wiley & Sons.

• Phillips, D. P., Brewer, K. M., & Wadensweiler, P. (2011). Alcohol as a risk factor for sudden infant death syndrome (SIDS). Addiction, 106, 526-7.

References• Streissguth, A. P., Barr, H. M., Kogan, J., & Bookstein, F. L. (1996).

Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE). Final report, Centers for Disease Control and Prevention Grant No. R04/CCR008515.

• Weatherill, L., & Foroud, T. Understanding the effects of prenatal alcohol exposure using three-dimensional facial imaging. (2011). Alcohol Research & Health, 34, 38-41.

• Wheeler, S. M., Stevens, S. A., Sheard, E. D. & Rovet, J. F. (2011). Facial memory deficits in children with fetal alcohol spectrum disorders. Child Neuropsychology, doi:10.1080/09297049.2011.613807