FASD and Behavioral Disorders in Context: Understanding Behavior of Alcohol-Affected Children

1. FASD and Behavioral Disorders in Context: Understanding Behavior of Alcohol-Affected Children Claire D. Coles, PhD Building State Systems Annual Meeting San Antonio, Texas June 20-22, 2005

2. Dr. Coles’ Affiliations • Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Maternal Substance Abuse and Child Development Laboratory (MSACD) • Fetal Alcohol Center, Marcus Institute, Center for Developmental Disabilities

3. Roger Bakeman, PhD (GSU) Josephine V. Brown, PhD Caroline Drews-Botsch, PhD Arthur Falek, PhD (Retired) Paul Fernhoff, MD Felicia Goldstein, PhD Julie A. Kable, PhD Theresa Gauthier, MD Karen Howell, PhD Mary Ellen Lynch, PhD Laura Namy, PhD Kathleen A. Platzman, PhD Mary Ann Romsky, PhD (GSU) Biomedical Imaging Technology Center Xiaoping Hu, PhD Xiangyang Ma, PhD Khalil Abdur-Rashid John P. Berg Felicia Berry, MA Raemelle Edwards Zarina Fershteyn MPH Chris Foster Mark Granados Christy Hall, Ph.D. Katrina C. Johnston, MA Michael Marcin, MD Tuesday Means Lynne Padgett, PhD Monitinique Pierre Mark Register, PhD Susan Schmiedling, RN Sharron Paige-Whitaker Geke van der Ende, MA Colleagues2005-Emory

4. Atlanta Fetal Alcohol Study (1980-2008) • Low SES, Predominantly African-American • Identified in Prenatal Clinic based on Maternal Drinking • Followed Longitudinally • Funded: NIAAA and Georgia DHR • This study: N=265

5. The FAS Clinic • A team of Professionals provides a diagnostic evaluation to assess for teratogenic effects of alcohol and drugs

6. FAS Clinic R. Dwain Blackston, MD Shena Leverett, LCSW Molly Millians, MEd Betsy Meeks, RN Jennifer Stapels, Ph.D. Mark Register, PhD Katrina C. Johnson, MA Research Staff and Colleagues Chris Cutcliffe, PhD Elles Taddeo, EdS Sam Maddox, MA Lynne Padgett, PhD Christy Hall, Ph.D. Virtual Reality Aids Dorothy Strickland, PhD FAS Center Staff Claire D. Coles, Ph.D, Director Julie A. Kable, Ph.D. Asst. Director

7. POSSIBLE MECHANISMS OF DRUGS/ALCOHOL IN PREGNANCY: Teratogenic (Single Factor) Model Outcome SIDS Fetal wastage Behavioral effects Birth Defects Growth retardation Teratogenic Substance Fetus Mother Coles, 1995,

8. SOME POSSIBLE MECHANISMS OF EFFECTS OF DRUGS/ALCOHOL IN PREGNANCY: Toxic (interactive) Model OUTCOMES Reduced fertility Fetal wastage Preterm birth Birth defects Growth retardation Behavior effects Mother Toxic Substance Fetus SECONDARY OUTCOMES Medical & behavioral problems SIDS Coles, 1995

9. OUTCOMES • Reduced fertility • Fetal wastage • Preterm birth • Birth defects • Growth • Retardation MULTI-FACTOR MODEL Prenatal Environment Social Factors Legal Issues Prenatal Care Substance Use & Abuse Maternal Characteristics Genetics FETUS SECONDARY OUTCOMES • Developmental & Medical • Effects • SIDS MOTHER POSTNATAL EVIRONMENT Maternal Status/ Legal issues/ Social Factors/ Nutrition/ Substance Use Abuse/ Education / Social Services/et cetera Coles, 1995

10. The brain is the basis for: • Cognition (thinking) • Attention • Learning • Language • Motor Skills • Behavior • Emotion

11. EFFECTS OF PRENATAL ALCOHOL EXPOSURE ON CNS Prenatal Exposure CNS RANGE OF EFFECTS BRAIN DAMAGE Autopsy Reports Animal Models MRI Studies Mental Retardation MBD Animal Models MRI Borderline IQ Behavioral Attention Deficits LEARNING DISORDERS Longitudinal Clinical Studies of FAS/FAE Exposed Children BEHAVIOR DISORDERClinical Reports UNAFFECTED Longitudinal Clinical Studies of Exposed Children

12. Normal development Conception Birth Post Natal Experience Outcomes typical optimal nonoptimal

13. Conception Development affected by Teratogen and by Postnatal Environment EtOH Birth Post Natal Environment Postnatal Experience Outcomes typical optimal nonoptimal

14. FASD and Social Behavior What does the research tell us?

15. (Some) Secondary Disabilities Attributed to Prenatal Exposure • Attention Deficit Hyperactivity Disorder • Deficits in Executive Functioning • Delinquency in Adolescence • Substance Abuse • Sexual Acting Out • Assorted behavioral disorders

16. School Failure Impaired Judgement Delinquency in Adolescence Sexual Acting Out Substance Abuse Mental Illness Moral Depravity Impaired Memory Failure to Learn from Experience Lack of Generalization Lying Attachment Disorder No Conscience Behaviors Attributed to Prenatal Alcohol-Exposure

17. Effects of Confounding Factors Prenatal alcohol exposure Poverty Disability Behavior Disorder Family Dysfunction

18. Problems in FAS: Clinical Samples • Mental Retardation/Low IQ • Learning Disabilities • Behavioral Disorders • Attention Deficit/Hyperactivity Disorder (ADHD) • Socialization • Academic Failure

19. Mental Retardation/Low IQ Learning Disabilities Behavioral Disorders Attention Deficit/Hyperactivity Disorder (ADHD) Socialization Academic Failure Problems in Clinical Samples without FAS

20. (Neuro) Behavioral Outcomes Examined in FASD • General Cognitive/Learning Skills (IQ) • Executive Functioning Skills • Attentional regulation • Memory,Planning and organization • Motor skills • Visual/spatial skills • Academic Achievement • Adaptive Behavior • Social Behavior • Mental Health/Behavioral Disorders

21. Global Effect? Early insults to brain result in widespread, relatively mild effects Behavioral Phenotype”? Specific areas of deficit attributed to exposure to specific drugs Is there a unique “signature”? What are the neurodevelopmental outcomes of exposure to a teratogenic agent? • “Heavy” Exposure? • Teratogenic outcomes (mortality, Dysmorphia, growth retardation, neurological damage)

22. Is there a Unique Effect of Prenatal Alcohol Exposure onBehavior? • Can we identify neurobehavioral outcomes that are the result of prenatal alcohol exposure? • Is there a distinct pattern that can be used for diagnosis in the absence of knowledge of prenatal exposure? • Does it matter?

23. Can we identify neurobehavioral outcomes that are the result of prenatal alcohol exposure? • Yes

24. Is there a distinct pattern of behavior that can be used for diagnosis in the absence of knowledge of prenatal exposure? • Not right now. Maybe never.

25. Doesit Matter? • Yes and No Yes, that it would be convenient and scientifically interesting No, in that clinically we need to treat those who come to our attention

26. Prenatal Alcohol Exposure and Behavior • Cognition • Arousal Regulation and Behavior Problems • Social Behavior • Substance Abuse

27. The Brain is “Plastic” • It grows and changes with experience • Zero to two is the “brain growth” time • It is constantly “rewired” by experience • Learning continues over the life span • “education” is the method

28. Functional Deficits Identified in Alcohol-Affected Individuals • General Cognitive/Learning Skills (IQ) • Executive Functioning Skills • Attentional/arousal regulation • Memory • Planning and organization • Academic Achievement • Math ability

29. “Specific” Problems Associated withFAS/pFAS and maybe FASD • Motor Problems • Visual-Spatial Deficits • Cognitive Deficits • Working Memory • Specific Academic Problems

30. Problems with Motor functioning Poor muscle tone Use utensils Tie Shoes Balance Fine motor skills handwriting Use of scissors Gross motor skills Running Riding a bike

31. Visual-Spatial Information • Perceiving • Judging • Storing --Images --Symbols • Experiencing --Space --Location

32. Visual-Spatial Deficits Difficulty judging • Patterns • Shapes • Relationships in space • Confusion over left-right Spatial Memory • Problems storing visual images in short and long term memory • Symbol recognition • Failure to use mental imagery

33. “attention”What is it? What’s a problem in FAS? • Noticing (“orienting”) • Arousal Regulation • Focusing (on the right thing) • Sustaining Attention • Encoding Information (entering it) • Shifting Attention (when it is time)

34. Effects on Information Processing and Attention at 7 years. • Slower, less efficient encoding of visual information. • Specific Deficits in Math Skills. Coles, et al, (1997) A comparison of children affected by prenatal alcohol exposure and attention deficit hyperactivity disorderACER, 21, 150-161

35. ADHD Problem focusing attention Problem inhibiting impulsive behavior High activity level and behavior problems FAS Problems learning information Slower processing Less efficient processing of visual information Problems with flexibility in problem solving ADHD vs. FAS

36. Factors Leading to confusion re: “Attention” and “ADHD” • Diagnosing ADHD • Confusing clinical and experimental Contexts • Defining “attention” • Failing to discriminate “attention” from other cognitive constructs like “memory” and “executive functioning”

37. Understanding Arousal Dysregulation

38. Factors that lead to Arousal Dysregulation • Temperament • Brain Dysfunction • Hyper-reactivity to environmental events • Attachment difficulties • Environmental Events • Stress

39. Alcohol and drug exposure: Research indicates that: • Newborns have higher heart rates • Infants show more sleep disorders • More problems in self-consoling • Arousal regulation and attention • Difficulties with self-regulation and Aggression at 24 months

40. Optimal “Arousal” Levels • There is an optimal “arousal level” for various human activities (e.g., sleep, attention, activity). • There is an optimal level for each person (experienced as affect state) • We strive to achieve this optimal level (e.g., coffee, food, music, alcohol, physical arousal, exercise, etc)

41. Does alcohol exposure predispose a child to later drug abuse? • 30 - 40% of FAS/pFAS population reported alcohol and other drug abuse problems, ages 12 - 20; for ages 21 - 51, 30 to 70%. (Streissguth, 1996).

42. Does alcohol exposure predispose a child to later drug abuse? • Lower rates than national sample: 71% of 10th graders vs. 50% of FAS/pFAS sample of 15 year olds reported “any use” of alcohol • Lower rates of cigarette use: 58% national sample vs. 29% of FAS/pFAS • Illicit drug use was very rare among our 15 year olds Coles, et al. , 1999

43. Does Alcohol Exposure Predispose A Child to Delinquent Behavior? • 60% of FAS/pFAS clients experienced trouble with the law (Streissguth, 1996) • Prenatal exposure associated with delinquency and criminal behavior (Fast et al., 1999)

44. High Levels of Delinquency May Not be Typical of Most Adolescents with FAS • Many of these studies have been completed based on samples of teens who already have been referred for professional services because of behavioral problems • These teens are probably the most severely affected and not representative of the broader spectrum of alcohol-affected adolescents

46. Predictors of Delinquency: Atlanta FAS Sample • Externalizing behaviors • Self-reported substance abuse • Higher number of negative life events • Lack of supervision • Inconsistent discipline provided by caregivers

47. Source: Lynch, et al. (2003) Examining delinquency in adolescents differentially prenatally exposed to alcohol.J Stud Alcohol, 64, pp. 678-686 It is widely reported that prenatal alcohol exposure is associated with later “criminal” behavior. But most studies didn’t controlled for environmental factors.

48. Conclusions: FAS and Delinquency • Delinquent behavior more strongly related to current environmental factors such as stressful life events and parental characteristics and behavior than to prenatal exposure to alcohol • Important to examine current family, peer and community influences in addition to exposure status