Teratogens

1. Teratogens Fetal Alcohol Syndrome Cocaine and Nicotine HIV/AIDS Revised 6.08 Development of Young Children with Disabilities#872.514 (61)Carol Ann Heath

2. Substance abuse is defined as: • A maladaptive pattern of using certain drugs, alcohol, medications, and toxins despite their adverse consequences. Barker, R.L. (1995). The social work dictionary, 3rd edition (pp. 370). Washington, DC: NASW Press.

3. Research on fetal alcohol syndrome and on the developmental defects linked to pregnant women's use of marijuana and cocaine have focused attention on the problem of maternal substance abuse.

4. Most cocaine users are "polydrug" users. • Almost all of them smoke cigarettes, smoke marijuana occasionally, and use alcohol. Some use other drugs like heroin and methamphetamine. • Alcohol and cigarettes are much more serious problems than cocaine in this country.

5. Lack of accurate estimates; • Prenatal substance exposure has significant, negative effects on developing children and infants; • Drug-abusing women and their children are particularly hard to reach; • Social service and drug treatment systems either do not have the appropriate family orientation to serve this population or simply do not have the capacity to do so.

6. History of Fetal Alcohol Syndrome • 1968 - 127 children born in France to alcoholic parents show multiple effects alcohol can have on developing fetus • 1973 - Fetal Alcohol Syndrome defined • 1979 - Diagnosis of FAS established by Research Society on Alcoholism • 1981 - Surgeon General Recommended abstaining from alcohol

7. There is no known safe amount of alcohol to drink while pregnant, and there does not appear to be a safe time to drink during pregnancy either. Centers for Disease Control

8. Basic Definitions • Alcohol-related birth defects (ARBD) • ARBD , a term coined by the Institute of Medicine in 1996, is used to describe individuals with confirmed maternal alcohol use and one or more congenital defects, including heart, bone, kidney, vision, or hearing abnormalities. • Alcohol-related neurodevelopmental disorder (ARND) • ARND , a term coined by the Institute of Medicine in 1996, is used to describe individuals with confirmed maternal alcohol use, neurodevelopmental abnormalities, and a complex pattern of behavioral or cognitive abnormalities inconsistent with developmental level and not explained by genetic background or environment. Problems may include learning disabilities, school performance deficits, inadequate impulse control, social perceptual problems, language dysfunction, abstraction difficulties, mathematics deficiencies, and judgment, memory, and attention problems. • Attention-deficit/hyperactivity disorder (ADHD) • The essential features of ADHD are a persistent pattern of inattention or hyperactivity/impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development. Children and adolescents with an FASD often meet the diagnostic criteria for ADHD. However, they may have co-occurring ADHD, or they may exhibit symptoms that look like ADHD but are due to other difficulties, including FASD.

9. Fetal alcohol effects (FAE) FAE is a term used to describe individuals exposed prenatally to alcohol who have some, but not all, of the features of FAS. These features may include developmental delay, cognitive impairments, and/or behavioral abnormalities. These individuals often have similar patterns of behavior to those with FAS but lack the characteristic facial features of FAS. FAE is a descriptive term and is not meant to be used as a diagnostic term. • Fetal alcohol spectrum disorders (FASD) FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical diagnosis. • Fetal alcohol syndrome (FAS) FAS is the term coined in the United States in 1973 by Dr. Kenneth Jones and Dr. David Smith at the University of Washington to describe individuals with documented prenatal exposure to alcohol and (1) prenatal and postnatal growth retardation, (2) characteristic facial features, and (3) central nervous system problems.

10. Fetal Alcohol Syndrome Defined • 1. Pre/Postnatal growth deficiency • Prenatal growth retardation (less than 10th percentile) • Postnatal growth retardation (less than 10th percentile)

11. Fetal Alcohol Syndrome Defined • 2. Central Nervous System Abnormalities • Mental retardation Hypotonia • Irritability in infancy Poor suck • Hyperactivity Seizures • Attention deficits • Tremulousness

12. Fetal Alcohol Syndrome Defined • 3. Craniofacial Abnormalities • Microcephaly Short palpebral fissures • Flat midface Indistinct philtrum • Thin upper lip Epicanthal folds • Low nasal bridge Minor ear anomalies • Short Nose • Micrognathia

13. Occasional Anomalies • Cleft lip or palate • Small teeth with “faulty” enamel • Limited joint movements • Cardiac • Renogenital • Skeletal

14. Spectrum of Abnormalities • Physical anomalies and mental retardation • Fetal Alcohol Effects (FAE): • normal or “typical” appearance • mild cognitive deficits • behavior problems • No overt signs or symptoms

15. Incidence • 1 in 200 births for alcohol related defects • 1-2 in 1000 for FAS • 3-5 in 1000 for FAE • 5-10% of women may drink at levels high enough to place fetus at risk • Chronic alcoholics have a 30-40% chance of having a child with related effects • 75% chance of second child affected • Risk increases with age

16. Performance • 80% Mental Retardation • 50% Fine motor issues • 80% Infant irritability, hyperactivity, attention deficits • 50% Hypotonia, poor coordination • Speech delay • Cognitive, behavioral, psychosocial problems

17. Development • Within first two years developmental delays become evident • School age - fine motor impairments • Adolescents - 2/3 will experience behavioral and emotional problems • IQ - average for FAS is 67

18. FAS is now recognized as the leading known cause of mental retardation in the United States

19. Intervention • Early Intervention Program • Speech therapy • Physical therapy • Special Education • Occupational therapy • Case manager • Behavior management

20. Smoking • The percentage of births to women who reported smoking during pregnancy dropped substantially during the 1990s, from 19.5 percent in 1989 to 10.2 percent in 2004 (preliminary estimate).

21. Smoking during pregnancy is associated with many adverse outcomes for children, such as premature birth, low birthweight, intrauterine growth retardation, stillbirth and infant mortality

22. "The hyperkinetic syndrome is the result of several causes and the effect of any single agent is difficult to discern. Although the apparent association with heavy maternal smoking, in methylphenidate (Ritalin)-sensitive cases, does not predicate a causal connection, it does justify a careful assessment of the possible role of tobacco addiction in the etiology of this common disorder.“ R. Denson, M.D.,  J.L. Nanson, M.A.,   M. A. McWatters, R.N.University of Saskatchewan, Canada

23. Child Test Scores Lower When Mothers SmokeA Study of 2nd and 5th Grade Students • This study of a large sample of children gives insights into the real dangers of smoking during pregnancy. Known as the National Child Development Study, in Britain, there were over 9,000 children measured to determine the effects of their mother’s smoking either 0, 10, or more than 10 cigarettes per day during pregnancy. When each child reached 7 and 11 years, there were a number of tests given to evaluate math ability, reading ability and general physical measurements. Results showed children of mothers who smoked 10 or more cigarettes a day are on average 1.0 centimeters shorter and between three and five months behind in reading, mathematics, and general ability when compared to the offspring of non-smokers, after allowing for associated social and biological factors (see fig.1 & 2). SOURCE: British Medical Journal, 4:573-575, 1973

24. Negative consequences for child health and development. Infants whose mothers smoke during pregnancy are three times more likely to die from Sudden Infant Death Syndrome as are babies whose mothers do not smoke during pregnancy.

25. Children born to mothers who smoked while pregnant, and possibly children whose grandmothers smoked while pregnant, have a higher risk of developing childhood asthma. • In addition, maternal smoking during pregnancy is a risk factor for early childhood overweight.

26. Smoking and Ethnicity • American Indian/Alaska Native women were the most likely to smoke during pregnancy, followed by non-Hispanic white women and non-Hispanic black women. • In 2004, 18.2 percent of American Indian or Alaska Native births, 13.8 percent of non-Hispanic white births, and 8.4 percent of non-Hispanic black births were to women who smoked during pregnancy (based on preliminary estimates). • Few Hispanic or Asian or Pacific Islander women smoked during pregnancy. In 2004, 2.2 percent of Asian or Pacific Islander births and 2.6 percent of Hispanic births were to women who smoked during pregnancy.

27. Smoking and Age • Young women ages 15 to 24 were much more likely than older women to smoke during pregnancy. • In 2003, the most recent year for which estimates are available, 15.4 percent of births to teens ages 15 to 19 and 16.1 percent of births to women ages 20 to 24 were to women who smoked during pregnancy, compared with less than 10 percent of births to women ages 25 and older.

28. Smoking and Education • Among women ages 20 and older, those with a college degree were the least likely to smoke during pregnancy. • In 2003, the most recent year for which estimates are available, less than two percent of births to college graduates were to women who smoked during pregnancy. • In contrast, 25.5 percent of women with 9 to 11 years of education smoked during pregnancy. Women with fewer than nine years of education were also relatively unlikely to smoke (6.2 percent).

29. Nicotine • Increases risk of miscarriage • Intrauterine growth retardation (LBW) • Effect on fetus related to amount smoked • Combined with caffeine or alcohol • Newborn period - subtle neurobehavioral abnormalities • Language and Cognitive deficits?

30. What is cocaine? • Cocaine is an alkaloid which is derived from coca leaves, most of which are grown in South America . It is a stimulant drug affecting the central nervous system. It makes people feel "high" and full of energy. It is similar in its effect to methamphetamines.

31. What is "crack"? • Crack is a processed form of cocaine which has been treated so that it can be absorbed into the bloodstream more rapidly.

32. Cocaine Use Leading Doctors, Scientists, and Researchers Request that Media and Policymakers Stop Perpetuating “Meth Baby” Myths

33. What is a "crack baby"? • There is no such thing as a "crack baby". • Term invented by the media to describe a baby whose mother used cocaine or crack during her pregnancy. • Since both the prenatal exposure and the parents' life style are important, such children are usually called, "children of substance abusing parents.“ Emory Department of Psychiatry and Behavioral Sciences, F and Q, Cocaine in Pregnancy

34. Leading CESARFAXU n i v e r s i t y o f M a r y l a n d , C o l l e g e P a r kA Weekly FAX from the Center for Substance Abuse ResearchAugust 15, 2005Vol. 14, Issue 33 “Although research on the medical and developmental effects of prenatal methamphetamine exposure is still in its early stages, our experience with almost 20 years of research on the chemically related drug, cocaine, has not identified a recognizable condition, syndrome or disorder that should be termed ‘crack baby’ nor found the degree of harm reported in the media and then used to justify numerous punitive legislative proposals.”

35. The terms “ice babies” and “meth babies” lack medical and scientific validity • These labels “harm the children to which they are applied, lowering expectations for their academic and life achievements, discouraging investigation into other causes for physical and social problems the child might encounter, and leading to policies that ignore factors, including poverty, that may play a much more significant role in their lives.”

36. No such thing as a “meth-addicted baby.” • Addiction is defined as “compulsive behavior that continues in spite of adverse consequences.” • Thus, by definition, babies cannot be “addicted” to methamphetamines or anything else.

37. physiologic dependence (not addiction) has been documented among infants exposed in utero to opiates • no dependence symptoms have been found following prenatal cocaine or methamphetamine exposure

38. Cocaine • Increased risk for premature births, LBW, and neurobehavioral abnormalities • Newborn withdrawal symptoms: • irritability tremors • restlessness abnormal sleep pattern • lethargy increased muscle tone • poor feeding high pitched cry

39. Neurobehavioral Abnormalities • Sleep state • Feeding • Attention • Irritability • Low threshold to overstimulation

40. Development • LBW • Abnormal muscle tone • Learning disabilities • Language delays • Behavior problems • Attention deficits • May be at risk for HIV infection

41. What's the biggest risk for cocaine-exposed children? • Two things • First, neglect and abuse by addicted parents who are not able to care for them properly • Second, labeling by public and professionals who confuse the effects of poor caregiving with the effects of prenatal exposure.

42. Intervention • Early Intervention program • Physical therapy • Speech therapy • Special Education • Behavior management

43. HIV/AIDS

44. History • Acquired immunodeficiency syndrome (AIDS) first described in early 1980’s. • Increasing rates among women and their newborns • 4th leading cause of death among women 25-44 • Associated with developmental delay in children

45. HIV in Children • First case reported in 1982 • By 1993, 15,000 children identified born with the HIV infection. • Approximately 7,000 children born in the U.S. are at risk for developing HIV. • 1,000 new cases reported each year of AIDS in children under 13.

46. Development • Near normal development until late in course of illness. • Two patterns of neurodevelopmental outcome: - 1. Progressive encephalopathy • affects 10-20% of infected infants • onset of symptoms between 6 and 24 months • infant will lose developmental milestones • death within 1-2 years

47. Development Continued • 2. Period of deterioration followed by a “plateau” of skills. • HIV infection causes subtle effects on cognitive development • Learning disabilities • ADHD • Speech delays (expressive language)

48. Intervention • Speech therapy • Physical therapy • Special education • Psychological testing • Behavior management

49. Other factors to consider • Other biological factors: drug exposure LBW prematurity Failure to Thrive • Long term hospitalizations • Family environment • Neglect

50. Intervention • Early intervention program • Physical therapy • Occupational therapy • Speech therapy • Special education • Psychological evaluations • Developmental evaluations