Preventing Alcohol Exposure and Fetal Alcohol Spectrum Disorders

Courtney Kihlberg, MD, MSPH

Assistant ProfessorDivision of Preventive

MedicineMeharry Medical College

Nashville, Tennessee18 May 2012

Funded by a grant from the Centers for Disease Control and Prevention (CDC) – 1U84DD000882

Funded by a grant from the Centers for Disease Control and

Prevention (CDC) – 1U84DD000882

No other support or disclosures

Preventing Alcohol Exposure and Fetal Alcohol Spectrum Disorders

DISCLOSURES

Objectives

Increase OB/GYN providers’ competency in preventing alcohol exposure during pregnancy

Review the epidemiology, screening tools, and diagnostic criteria for fetal alcohol spectrum disorders

Examine evidence-based practices in prevention, identification of, and multidisciplinary interventions for fetal alcohol spectrum disorders

Presentation OutlineExplore barriers

healthcare providers face with FASD prevention, diagnosis, & care

Examine diagnostic criteria

Review epidemiologic data

Practice alcohol screening & prevention techniques

Discuss intervention & treatment options

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

Overcoming Barriers

“Practice Makes Perfect”

Queried one of your pregnant moms on alcohol intake in the household?

Considered alcohol exposure in a women with a child from a prior pregnancy who has: Learning or behavioral difficulties

(e.g. ADHD)? Organ or growth abnormalities? Dysmorphic features?

How often do you andhow recently have you…

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.

Breaking Down Barriers

Neonatal diagnosis is NOT a hopeless prognosis

Appropriate medical interventions + Community support =

Minimized (though not eliminated) impact of alcohol-related

birth injury and neurodevelopmental disabilities

Prevention in Future Pregnancies

Diagnostic Criteria

3 (+3 ) ± 1 = FAS

3 Requirements3 Embedded Requirements

1 “Given” Not Required

Criteria for Diagnosing FASWith or WITHOUT confirmed fetal

exposure to alcohol, diagnosis requires documentation of

All three dysmorphic facial features smooth philtrum, thin vermillion border, small

palpebral fissuresPre- or post-natal growth deficit Structural, neurologic, or functional central nervous system (CNS) abnormality

Bertrand J, Floyd RL, Weber MK. Morbidity and Mortality Weekly Review. October 28, 2005/54;1-10

#1 Facial Abnormalities of FAS

1. Smooth philtrum

2. Thin vermillion border

3. Small palpebral fissures

Photo courtesy of Teresa Kellerman

Lip-Philtrum GuideDeveloped by University of

Washington FAS Diagnostic & Prevention Network

Guide 1 – CaucasiansGuide 2 – African Americans

Back 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

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.

Measuring the Palpebral Fissures

http://depts.washington.edu/fasdpn/images/pfl-eyesopen2006a.jpg accessed July 1, 2011.

Comparing Palpebral Fissure Measurements to Norms

Active excel spreadsheet accessed from http://depts.washington.edu/fasdpn/htmls/diagnostic-tools.htm on July 1, 2011.

Accuracy of Methods for Measuring Palpebral Fissure

Lengths

Clear Plastic Ruler42% concordant with photometric measures

Discordance: ruler equally smaller and larger

Blunt Precision Slide Calipers18% concordant with photometric measures

24% concordant with ruler measures

Discordance: calipers usually measured larger

Cranston, et al. Concordance of Three Methods for Palpebral Fissure Length Measurement in the Assessment of FASDs. Can J Clin Pharmacol, 2009.

Streissguth, 1994

Photos 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 these photos requires written permission from the University of Louisville FASD Clinic - Weisskopf Child Evaluation Center and the proper acknowledgement as written in this caption. 

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.

http://depts.washington.edu/fasdpn/htmls/face-software.htm accessed July 1, 2011.

#2 Growth Deficits in FAS

TimingPrenatal or PostnatalAt any one point

Degree≤ 10th percentile for age and sex

adjusted for gestational ageHeight or Weight (or Head

Circumference)

#3 CNS Abnormalities of FAS

Structural AbnormalityHead

Circumference ≤ 10th percentile

a. 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. MMWR. October 28, 2005/54;1-10.photo: Clarren, 1986.

Corpus Callosum Structural Abnormality

A: 14 year old control subject: Normal corpus callosumB: 12 year old with FAS: Thin corpus callosumC: 14 year old with FAS: Agenesis of the corpus callosum

Mattson, S.N.; Jernigan, T.L.; and Riley, E.P. 1994. MRI and prenatal alcohol exposure: Images provide insight into FAS. Alcohol Health & Research World 18(1): 49-52. (used with permission)

#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 AbnormalityGlobal 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 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

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.

FASD 4-Digit Diagnostic Code

Ranks each of the following on a 4 point scale: GrowthFaceCNSAlcohol Exposure

256 possible 4-Digit Code combinations

All combinations assigned to one of 22 Diagnostic Categories

Astley, SJ. Diagnostic Guide for FASD: The 4-Digit Code, 3rd Edition, 2004. Accessed from http://depts.washington.edu/fasdpn/pdfs/guide2004.pdf on July 5, 2011.

Astley, SJ. Diagnostic Guide for FASD: The 4-Digit Code, 3rd Edition, 2004. Accessed from http://depts.washington.edu/fasdpn/pdfs/guide2004.pdf on July 5, 2011.

Astley, SJ. Diagnostic Guide for FASD: The 4-Digit Code, 3rd Edition, 2004. Accessed from http://depts.washington.edu/fasdpn/pdfs/guide2004.pdf on July 5, 2011.

From FAS Diagnostic Criteria to Life with an FASD….

IQ averages 60, range 20-110

Poor JudgmentProblems with

BehaviorMotor SkillsSocial Interactions

Excessive body contactImpulsivenessIntrusivenessLack of stranger anxiety

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

…. Even Beyond Early Childhood

Disrupted Schooling43% of teens with FASDs are at high risk of

having school interrupted by suspension, expulsion, or from dropping out

Conduct ProblemsAntisocial BehaviorsInability to follow rules, lying, and stealing

Difficulties SocializingMaintaining FriendshipsDepression and Anxiety Inappropriate Sexuality

GOALIndependent Living

0.2 to 1.5 per 1,000 caveats

Actually DiagnosedFAS vs. FASD

Regional Variances

Epidemiology of FASDs

Incidence of FASDs

Comparable with or higher than rates for other common developmental disabilities (Down syndrome, spina bifida)

0.2 to 1.5 cases of FAS per 1,000 live births in the US

Rates in other studies range from 0.5 to 2.0 cases per 1,000

Other FASDs are believed to occur about 3 times as often as FAS

CDC. MMWR Morb Mortal Wkly Rep 2002;51:433-435.

CDC. A Call to Action: Advancing Essential Services and Research on Fetal AlcoholSpectrum Disorders. March 2009. Accessed from www.cdc.gov/ncbddd/fasd/douments/calltoaction.pdf.

Prevalence in Other Countries

South AfricaHighest reported prevalence rates of FAS

in the worldIn 2000: 40.5 - 46.4 per 1,000 childrenIn 2002: 65.2 - 74.2 per 1,000 childrenIn 2011: 70 – 80 per 1,000 children

(partially attributed to increase in provider awareness and recognition of diagnosis)

Russia20% of children in Moscow orphanages

and boarding schools had physical features of FAS (N=1,000)

May et al., Am. J. of Public Health 90 (2000); Viljoen et al., J. Stud. Alcohol 66 (2005). Riley et al, Alcohol Clin Exp Res (2003). Bulletin of the World Health Organization 2011;89:398–399. doi:10.2471/BLT.11.020611

Reported incidence rate of FAS, by year of birth, CDC Birth Defects Monitoring Program, 1979-1992

Courtesy: NIAAA webpage. Cordero, J.F., et al. Alcohol Health & Research World 18(1):82–85, 1994.

Prevalence of Alcohol Use Among Women of Childbearing Age

Known vs. Unknown Pregnancies

Frequency of UseOccasional / Any UseBinge

4 or more drinks on one or more occasions for women

5 or more drinks on one or more occasion for men

Kanny, Liu, Brewer. “Binge drinking – United States 2009.” CDC, MMWR.Photo: courtesy of Dang, CDC.

Accessed from www.cdc.gov/ncbddd/fasd/data.html on May 14, 2012.

State-specific weighted prevalence estimates of Alcohol use among Women Aged 18–44 Years,BRFSS, 2010

State Any Use* Binge†

Florida 49.7 13.5Utah 21.5 7.0

Wisconsin 67.7 22.7

US (median) 51.2 15.2

• * 1 or more drinks during the last 30 days• † 4 or more drinks on any one occasion during the last 30 days • standard drink: 0.60 ounces of pure alcohol equivalent to one 12-ounce beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80 proof distilled spirits [hard liquor]

344.1

2.9

24.7

9.1

18.618.7

26.1

23.2

35.1

0

5

10

15

20

25

30

35

40

Total White Black Hispanic AmericanIndian

Asian Morethan 1race

Perc

enta

ge

PregnantNot Pregnant

Females Aged 15-44 Years Reporting Past Month Binge† Alcohol Use, by Race/Ethnicity and Pregnancy Status, 2002 and 2003 Combined

† Binge = 5 or more drinks on the same occasion on at least 1 day in the past 30 days

Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health 2005

Race/Ethnicity Percent

White 63Hispanic or Latino 39.7African American 38.5

Alcohol consumption among adults 18 years of age and over, by selected characteristics: United States, 1997, 2004, 2005. From National Center for Health Statistics. Health, United States, 2007. Table 68 (1 of 3). Hyattsville, MD: 2007.

Percentage of Female (>18 years of age) Current Drinkers by

Race/Ethnicity

Race Percent

White 22.6Hispanic or Latino 16.9African American 13

Alcohol consumption among adults 18 years of age and over, by selected characteristics: United States, 1997, 2004, 2005. From National Center for Health Statistics. Health, United States, 2007. Table 68. Hyattsville, MD: 2007.

Percentage of Female (>18 years of age) Binge † Drinkers by

Race/Ethnicity

† Binge = 5 or more drinks on the same occasion on at least 1 day in the past year

Stomach

Brain

Liver

Kidneys

Fetus

Muscles

Nerves

Placenta

Brain

Heart

Organs

                           

  

Breast

Biologic Plausibility and Mechanism of Action

Alcohol’s Effects on the Developing Fetus

abnormal nerve cell proliferation cell growth, division, survival

altered cell membranesbiochemical/electrical signalingintracellular calcium regulation gene expression

impaired nerve cell migration (astrocytes)cell adhesionaxon formation

free radical formation

NIAAA, 2000

Areas of the brain that can be damaged in utero by maternal alcohol consumption

Warren & Foudin. Alcohol Research & Health 25(3):153–158, 2001.

Major Effects of Alcohol by Trimester

Courtesy UCLA RTC.

Baldwin. Fetal Alcohol Spectrum Disorder, Florida Resource Guide. Accessed from http://www.doh.state.fl.us/family/socialwork/pdf/fasd.pdf on April 30, 2012.

Any Volunteers?

How to screen for and prevent alcohol use in

pregnancy

Time to TWEAK your neighbor

TWEAK Alcohol Assessment

Originally developed to screen for at-risk drinking during pregnancy

Proven effectiveness in pregnant women and African-American women of low SES

Five-item scale

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-Opener"Do you sometimes take a drink in the morning when you first get up?"

A - Amnesia "Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?" (blackouts)

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 pointsWorry: Yes = 2 pointsEye Opener: Yes = 1 pointAmnesia: Yes = 1 pointCut Down: Yes = 1 point

Pregnant WomenScore of >0 indicates at-risk drinking

Non-PregnantScore of 2 indicates likelihood of at-risk drinkingScore of ≥ 3 indicates problem drinking or alcoholism

Chang G. Alcohol Research and Health. 2001;25(3):204-209.

Audio Computerized Self-Report Interview

Ear phones used with recorded voice asking questions

TWEAK plus questions on quantity and frequency during 3 months prior to pregnancy through present

Validated in low SES, low literacy minority population

Thornberry, et al. Nursing. 2002; 20(2):46-52.

Baldwin. Fetal Alcohol Spectrum Disorder, Florida Resource Guide. Accessed from http://www.doh.state.fl.us/family/socialwork/pdf/fasd.pdf on April 30, 2012.

Ask, Assess, Advise, Assist Method

AskDo you drink alcohol, including beer, wine or hard

liquor?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?

Assess: Know what a standard drink is

www.uwsuper.edu/.../images/alcohol.jpg

Advise and Assist

Brief Interventions have been found to be effective with female problem drinkers in primary-care clinics

5-10 minute counseling session can reduce alcohol use in women by 20-30%

Wallace P, et al. BMJ1988;297(6649):663-668. Fleming MF, et al. 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 Assist4. 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

NIAAA, Office of Research on Minority Health, Identification of At Risk Drinking and Intervention with Women of Childbearing Age. NIH Publication No. 99-4368 (1999)

Start with the Basics!

Decrease unintended pregnanciesInitiate contraceptive effortsConfirm proper and

consistent use

Example from Project CHOICES Changing High-Risk AlcOhol Use &

Increasing Contraception Effectiveness Study

Photo: courtesy Dang, CDC.

Project CHOICES

4 motivational counseling sessions and a contraception consultation visit delivered over 12-14 weeks

At 3, 6, and 9 month follow-up, the odds for reducing the risk of an Alcohol Exposed Pregnancy (AEP) were 2-fold higher among women receiving the intervention as compared to the control group.

4 motivational counseling sessions and a contraception consultation visit delivered over 12-14 weeks

At 3, 6, and 9 month follow-up, the odds for reducing the risk of an Alcohol Exposed Pregnancy (AEP) were 2-fold higher among women receiving the intervention as compared to the control group.

Floyd, et al. Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial American Journal of Preventive Medicine; January 2007; 32(1):1-10.

It may be difficult to talk with patients about

alcohol use and the prevention of FASDs, butyou can do it

and there are resources that can help!

Improving Healthcare Provider Practices

Partners& Policy

Monitoring

HealthEducation

& Promotion

CDC’s FAS

Prevention Team

Dissemination

of Effective Interventions

Intervention Research

Elizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

FASD Regional Training Centers (RTCs)

In 2002, Congressional language indicated that the CDC would…Develop guidelines for the diagnosis of FAS

and other prenatal alcohol-related conditionsIncorporate these guidelines into curricula for

medical and allied health students and practitioners

CDC funded the original four RTCsSoutheast: Meharry Medical CollegeNortheast: Univ of Med & Dentistry of New

JerseyMidwest: Saint Louis UniversityWest: UCLA

Elizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

Current RTCs 2011-2014

Southeast: Meharry Medical College

Great Lakes: Univ of Wisconsin

Arctic: Univ of Alaska,Anchorage

Frontier: Univ of Nevada, Reno

Midwest: Saint Louis Univ

http://www.cdc.gov/ncbddd/fasd/training.html accessed April 30, 2012.

Tools from www.cdc.gov/fasd

Adapted from Elizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention

Developed by ACOG and CDCBrief guideLaminated screening

instrumentResource informationPatient handouts

Pocket CardiPhone App

FASD Prevention Tool Kits

Accessed from http://www.womenandalcohol.org/clinicians.html on April 30, 2012.

Prevention Materials Targeting Specific Groups

Iowa

St. Louis, MO

Los Angeles County, California

FASDs are 100% preventablethere 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”

For those living with an FASD

FASD Interventions and Treatments

Multidisciplinary Approach is CriticalMedical Treatment Mental Health Treatment

PharmacotherapyBehavioral Therapies and

InterventionsSkilled Nursing ServicesPhysical, Occupational, and Speech

TherapyEducational Interventions

Early Intervention ServicesExceptional EdTeacher 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.

SAMHSA, 2007.

Development of Individual Education Plans

(IEPs)

Teaching Students with Fetal Alcohol Syndrome/Effects. British Columbia, 1996. Accessed from http://www.bced.gov.bc.ca/specialed/fas/ on June 15, 2011.

Resources for Educators

Multidisciplinary Approach is Critical

Caregiver SupportSpecial consideration for Birth Mothers

Parent Training

http://www.nofas.org/coh/default.aspx

Multidisciplinary Approach is Critical

Case ManagementArt and Music

TherapyService Animals…. and more….

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

Marcus InstituteLearning readinessMath

U. OklahomaHealth Sciences

PreschoolerBehavior

U. Washington Clinically Sig. Behavior Problems

U. CaliforniaLos Angeles

Friendships Social skills

Children’s Research Triangle

Executive Functioning

CDC

Intervening

with Children

with FASDs

Elizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, CDC.

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) 327-5525 www.fasdsoutheast.org

Pensacola Resources

Florida Department of Healthwww.doh.state.fl.us/family/mch/substanceabuse/alcohol/profas_friends.html

Link to the 2005 guide from FSU Center for Prevention and Early Intervention Policy

Healthy Start being redesigned from April 2011 – March 2013

Florida Alcohol and Drug Abuse Associationwww.fadaa.org

Funded by a grant from the Centers for Disease Control and

Prevention (CDC) – 1U84DD000882

Preventing Alcohol Exposure and Fetal Alcohol Spectrum Disorders

QUESTIONS