Fetal Alcohol Spectrum Disorder

1. Fetal Alcohol Spectrum Disorder Dr. Brenda Stade, RN 416-867-3655 stadeb@smh.toronto.on.ca Brenda Stade, PhD 2008 www.FASEout.ca

2. In Canada the incidence of Fetal Alcohol Spectrum Disorder (FASD) has been estimated to be 1 to 9 in 1000 live births. Brenda Stade, PhD 2008 www.FASEout.ca

3. Introduction • Caused by prenatal exposure to alcohol • FASD is the leading cause of developmental and cognitive disabilities among Canadian children Brenda Stade, PhD 2008 www.FASEout.ca

4. Etiology • Alcohol readily crosses the placenta and results in similar levels in the mother and fetus • Rate of elimination is slower in the fetus • Most teratogenic effect during organogenesis and development of the nervous system Brenda Stade, PhD 2008 www.FASEout.ca

5. Etiology When neuronal activity is abnormally suppressed during the developmental period, the timing and sequence of synaptic connections is disrupted, and this causes nerve cells to receive an internal signal to commit suicide, a form of cell death known as "apoptosis". • Addiction Biology 2004 Jun;9(2):137-49. Brenda Stade, PhD 2008 www.FASEout.ca

6. Etiology Alcohol suppresses neuronal activity, causing millions of nerve cells to commit suicide in the developing brain. This effect of alcohol provides a likely explanation for the diminished brain size and lifelong neurobehavioral disturbances associated with the fetal alcohol syndrome. • Addiction Biology 2004 Jun;9(2):137-49. Brenda Stade, PhD 2008 www.FASEout.ca

7. Etiology • Teratogenesis is grossly dose related, although the threshold dose is still unknown and related to maternal/fetal susceptibility • Risk to fetus greatest with more than 7 or more standard drinks per week (1 standard drink = 13.6 grams of absolute alcohol) • Binge drinking of more than 5 ounces ( 142 grams) on one occasion Brenda Stade, PhD 2008 www.FASEout.ca

8. Etiology • No safe time to drink during pregnancy • No known safe amount Brenda Stade, PhD 2008 www.FASEout.ca

9. Fetal Alcohol Spectrum Disorder: Defined • Facial Anomalies • Growth Restriction • CNS Dysfunction Brenda Stade, PhD 2008 www.FASEout.ca

10. Facial Features Brenda Stade, PhD 2008 www.FASEout.ca

11. Growth Restriction • Growth restriction is demonstrated by height and weight below the tenth (10th) percentile, and by microcephaly • Growth restriction may be apparent prenatally and/or postnatally Brenda Stade, PhD 2008 www.FASEout.ca

12. Central Nervous System Dysfunction • Decreased Cranial Size at Birth • Structural Brain Abnormalities: microcephaly, partial or complete agenesis of the corpus callosum, cerebellar hypoplasia • Neurobehavioral/Cognitive Signs Brenda Stade, PhD 2008 www.FASEout.ca

13. Neurobehavioral/Cognitive Signs:Infancy • Tremors • Poor suck • Hypotonic/Hypertonic • Irritability • Feeding problems • Developmental delay Brenda Stade, PhD 2008 www.FASEout.ca

14. Neurobehavioral/Cognitive Signs:Beyond Infancy • Cognitive problems • Fine motor issues • Hyperactivity • Restlessness • Poor ability to focus attention Brenda Stade, PhD 2008 www.FASEout.ca

15. Neurobehavioral/Cognitive Signs • Cognitive problems: • Verbal IQ • Performance IQ • Scatter in Cognitive Skills • Specific Learning Disabilities • Memory Deficits • Executive Functioning Brenda Stade, PhD 2008 www.FASEout.ca

16. working memory planning time perception internal ordering self-monitoring regulation of emotion motivation inhibition Executive functions ofthe prefrontal cortex Brenda Stade, PhD 2008 www.FASEout.ca

17. Neurobehavioral/Cognitive Signs • Poor Judgement • Impulsiveness • Sleep disturbances • Extreme anxiety • Depression • Aggressiveness • Other Behavioural Problems Brenda Stade, PhD 2008 www.FASEout.ca

18. Associated Anomalies • Cardiac anomalies • Joint and limb anomalies • Neurotubal defects • Anomalies of the urogenital system • Hearing disorders • Visual problems • Severe dental malocclusions Brenda Stade, PhD 2008 www.FASEout.ca

19. Diagnosis: Diagnostic Criteria Brenda Stade, PhD 2008 www.FASEout.ca

20. Classification of FASD • FAS with confirmed maternal alcohol exposure • FAS without confirmed maternal alcohol exposure • Partial FAS with confirmed maternal alcohol exposure • Alcohol-Related Birth Defect (ARBD) • Alcohol-Related Neuro-Developmental Disorder (ARND). • American Academy of Pediatrics, 1996. Brenda Stade, PhD 2008 www.FASEout.ca

21. #1: Fetal Alcohol Syndrome with confirmed prenatal exposure to alcohol is characterized by a triad of signs: • Facial Anomalies: short palpebral fissures, flat philtrum, and thin vermillion border of the upper lip • Growth Restriction: weight and height (length) at or below the 10th percentile • Central Nervous System Dysfunction: Structural abnormalities of the brain, intellectual impairment, developmental delay and a complex pattern of behaviours including extreme hyperactivity, poor judgment and aggressiveness Brenda Stade, PhD 2008 www.FASEout.ca

22. #2: Fetal Alcohol Syndrome without confirmed prenatal exposure to alcohol: • If the triad of signs described in category 1 is present, an diagnosis of Fetal Alcohol Syndrome can be made without confirmed alcohol exposure during gestation. Brenda Stade, PhD 2008 www.FASEout.ca

23. #3: Partial Fetal Alcohol Syndrome (PFAS) with confirmed alcohol exposure: • This diagnostic term is used when the patient presents with central nervous system dysfunction and most (but not all of the growth and/or facial features of FAS), and has a confirmed prenatal alcohol exposure Brenda Stade, PhD 2008 www.FASEout.ca

24. #4: Alcohol-Related Birth Defects (ARBD) • Patients in this category will have congenital malformations such as cardiac anomalies, joint and limb anomalies, and confirmed prenatal alcohol exposure Brenda Stade, PhD 2008 www.FASEout.ca

25. #5: Alcohol-Related Neuro-Developmental Disorder (ARND) • Patients with ARND present with neuro-cognitive dysfunction and complex patterns of behaviour, and have a confirmed exposure to alcohol prenatally • Patients with ARND may not demonstrate any of the facial features or growth restriction associated with the full syndrome Brenda Stade, PhD 2008 www.FASEout.ca

26. New Classification of FASD • FAS with or without confirmed maternal alcohol exposure • Partial FAS with confirmed maternal alcohol exposure • Alcohol-Related Neuro-Developmental Disorder (ARND). • Alcohol-Related Birth Defects (ARBD) • CMAJ, March 2005. Brenda Stade, PhD 2008 www.FASEout.ca

27. Differential Diagnosis A number of genetic and malformation syndromes can present with clinical features similar to FASD and must be ruled out Brenda Stade, PhD 2008 www.FASEout.ca

28. Differential Diagnosis • A number of genetic and malformation syndromes can present with clinical features similar to FASD: Cornelia de Lange Syndrome Dubowitz Syndrome Fragile X Velocardiofacial Syndrome Williams Syndrome Brenda Stade, PhD 2008 www.FASEout.ca

29. When to Diagnosis? A diagnosis of FASD can be made at any time during life but it is often most easily made at the age of 18 months to 4 years when the facial characteristics are most distinct Brenda Stade, PhD 2008 www.FASEout.ca

30. Why Diagnose? Validation • New understanding leads to new strategies at home and other environments • Funding in school and daycare • Opening doors for family services • Better medical management • Prevention of secondary disabilities • Prevention of future alcohol affected children Brenda Stade, PhD 2008 www.FASEout.ca

31. Primary Disabilities: Organ Anomalies • Cardiac anomalies • Joint and limb anomalies • Neurotubal defects • Anomalies of the urogenital system. • Hearing disorders • Visual problems • Severe dental malocclusions Brenda Stade, PhD 2008 www.FASEout.ca

32. Primary Disabilities: Central Nervous System • Tremors • Poor suck • Hypotonic/Hypertonic • Irritability • Feeding problems • Developmental delay Brenda Stade, PhD 2008 www.FASEout.ca

33. Primary Disabilities: Central Nervous System • Cognitive problems • Fine motor issues • Hyperactivity • Restlessness • Poor ability to focus attention Brenda Stade, PhD 2008 www.FASEout.ca

34. Primary Disabilities: Central Nervous System • Cognitive problems: • Verbal IQ • Performance IQ • Scatter in Cognitive Skills • Specific Learning Disabilities • Memory Deficits • Executive Functioning Brenda Stade, PhD 2008 www.FASEout.ca

35. working memory planning Time perception internal ordering self-monitoring regulation of emotion Motivation inhibition Executive functions ofthe prefrontal cortex Brenda Stade, PhD 2008 www.FASEout.ca

36. Primary Disabilities: Central Nervous System • Poor Judgement • Impulsiveness • Sleep disturbances • Extreme anxiety • Depression • Aggressiveness • Other Behavioural Problems Brenda Stade, PhD 2008 www.FASEout.ca

37. Interventions:Medical Brenda Stade, PhD 2008 www.FASEout.ca

38. Interventions: Medical • Referral to appropriate specialist: Cardiologist Orthopedics Nephrologist • Hearing Testing • Visual Testing • Follow Growth • Dental Care • ?? Medication Brenda Stade, PhD 2008 www.FASEout.ca

39. Interventions:Neuro-Developmental Brenda Stade, PhD 2008 www.FASEout.ca

40. Interventions: Neuro-Developmental • Developmental Assessment • Early Intervention Programs – Cognitive & Fine Motor • Pre-School Speech and Language Program • Occupational Therapist Brenda Stade, PhD 2008 www.FASEout.ca

41. Interventions: Neuro-Developmental • Neuro-developmental or Psychological Assessment • Modification of School Programs • Decrease Class Size 8 to 10 • Resource Teacher/Educational Assistant • Individual Educational Plan • Speech Therapist- through school board Brenda Stade, PhD 2008 www.FASEout.ca

42. Interventions: Neuro-Developmental • Challenge – Don’t Overwhelm • Ensure expectations are reasonable with opportunities to succeed Brenda Stade, PhD 2008 www.FASEout.ca

43. Interventions:Psycho-social Brenda Stade, PhD 2008 www.FASEout.ca

44. Interventions: Psycho-social • Early Intervention Programs – Behavioural, Social • Activities child enjoys that foster self-esteem and social development • Psychiatry • ? Medication Brenda Stade, PhD 2008 www.FASEout.ca

45. Interventions: Psycho-social – Family • Listening & Support • Counselling • Depression not uncommon and may need treatment • Support Groups Brenda Stade, PhD 2008 www.FASEout.ca

46. Thank you! Brenda Stade, PhD 2008 www.FASEout.ca