Fetal Alcohol Syndrome and Fetal Alcohol Syndrome and Alcohol- Related Alcohol- Related

Neurodevelopmental DisorderNeurodevelopmental Disorder

William T. Greenough, Ph.D., and Anna Y. Klintsova, Ph.D.William T. Greenough, Ph.D., and Anna Y. Klintsova, Ph.D.Depts. Psychology, Psychiatry, Cell & Structural Biology andDepts. Psychology, Psychiatry, Cell & Structural Biology andBeckman Institute, University of Illinois, Urbana-ChampaignBeckman Institute, University of Illinois, Urbana-Champaign

Largely based on the work of Ann Streissguth and colleaguesLargely based on the work of Ann Streissguth and colleagues

If you view your role as a physician primarily as one of prescribing and providing medical treatments for illnesses and disorders, you probably won’t be very

good at it.

Fetal alcohol syndrome and alcohol-related neurodevelopmental disorder illustrate a different

aspect of a physician’s role.

Characteristic Facial Features of Child with FASCharacteristic Facial Features of Child with FAS

Short Eyelid Opening, Flat Midface, Short Nose, Indistinct Short Eyelid Opening, Flat Midface, Short Nose, Indistinct Philtrum (depression beneath the nose), Thin Upper Lip, Epicanthal Philtrum (depression beneath the nose), Thin Upper Lip, Epicanthal Folds, Low Nasal Bridge, Minor Ear Abnormalities, Short ChinFolds, Low Nasal Bridge, Minor Ear Abnormalities, Short Chin

Corpus callosum agenesis in FAS patientsCorpus callosum agenesis in FAS patients

(From Mattson et al., 1994)(From Mattson et al., 1994)

ControlControl Thin c.callosumThin c.callosum Absent c.callosumAbsent c.callosum

MR images of 9-year old girl with FAS

C. callosum agenesis

Courtesy of Dr. Sarah Mattson, SDSU

Colpocephaly

Brain Size Changes in FASBrain Size Changes in FAS

Whole Brain

200000

250000

300000

350000

400000Controls

FAS

Cerebellum

30000

35000

40000

45000

50000

p = .0003

p = .0001

Courtesy of Dr. Sarah Mattson, SDSU

FAS FAE/ARNDFAS FAE/ARND

•facial dysmorphology

• growth retardation

• microcephaly and

neuropathology

(behavioral impairment)

•proven maternal

alcohol consumption

• growth retardation

• brain damage

• behavioral impairment

IQ distribution for FAS and FAE compared IQ distribution for FAS and FAE compared with the normal curvewith the normal curve

(From Streissguth et al., 1996)(From Streissguth et al., 1996)

Prevalence of Secondary Disabilities across the Life SpanPrevalence of Secondary Disabilities across the Life Span

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

History of Secondary Disabilities by three age groups History of Secondary Disabilities by three age groups at interviewat interview

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 19961996

History of Mental Health Problems (MHP) by sex, History of Mental Health Problems (MHP) by sex, diagnosis and age at interview (n=415)diagnosis and age at interview (n=415)

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

History of Mental Health Problems by age History of Mental Health Problems by age at interview (n=415)at interview (n=415)

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

Learning problems by age at interview (n=395-407)Learning problems by age at interview (n=395-407)

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

Repeated behavior problems by age Repeated behavior problems by age at interview (n=403-408)at interview (n=403-408)

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

History of Confinement: Components of the Secondary History of Confinement: Components of the Secondary Disability by age at interview (n=410-415)Disability by age at interview (n=410-415)

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

Prevalence of sexual victimization, therapy for ISB, and Prevalence of sexual victimization, therapy for ISB, and trouble with the law for sexual behavior by six common trouble with the law for sexual behavior by six common

inappropriate sexual behaviors: Among femalesinappropriate sexual behaviors: Among females

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

Prevalence of sexual victimization, therapy for ISB, and Prevalence of sexual victimization, therapy for ISB, and trouble with the law for sexual behavior by six common trouble with the law for sexual behavior by six common

inappropriate sexual behaviors: Among malesinappropriate sexual behaviors: Among males

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

History of Alcohol/Drug Problems (ADP) by sex, diagnosis History of Alcohol/Drug Problems (ADP) by sex, diagnosis and age at interview and age at interview

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

Prevalence of Dependent Living (DPL), by sex and Prevalence of Dependent Living (DPL), by sex and diagnosisdiagnosis

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

History of Problems with Employment (PWE) History of Problems with Employment (PWE) among clients > 21 years old, by sex and diagnosis (n=90)among clients > 21 years old, by sex and diagnosis (n=90)

Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996Source: Streissguth et al. Final CDC Report on Secondary Disabilities, 1996

Five Environmental Protective FactorsFive Environmental Protective Factors

• Stable and Nurturing Good Quality HomeStable and Nurturing Good Quality Home

• Infrequent Changes of HouseholdInfrequent Changes of Household

• Not Being a Victim of ViolenceNot Being a Victim of Violence

• Having Received Developmental Disabilities ServicesHaving Received Developmental Disabilities Services

• Having Been Diagnosed Before 6 Years of AgeHaving Been Diagnosed Before 6 Years of Age

--Streissguth, 1997--Streissguth, 1997

Educational and public information efforts have not yet effectively reduced the incidence of fetal-

alcohol spectrum disorders; to the contrary, risk drinking during

pregnancy, including binge drinking, actually increased in the United States between 1991 and

1995 ---Ebrahim, 1999

How Much is Too Much?How Much is Too Much?

Outcome of maternal drinking during Outcome of maternal drinking during pregnancy depends on:pregnancy depends on:

• stage(s) of fetus development when drinking occurredstage(s) of fetus development when drinking occurred

• peak BAC reached during drinking episode(s)peak BAC reached during drinking episode(s)

• mother’s individual situation (health and build, nutritional mother’s individual situation (health and build, nutritional status, level of alcohol dehydrogenase)status, level of alcohol dehydrogenase)

One drink is too much for a mother at riskOne drink is too much for a mother at risk

(From Little et al., 1984)(From Little et al., 1984)

Change in Drinking by pregnant women Change in Drinking by pregnant women after contact with Seattle Pregnancy and Health Programafter contact with Seattle Pregnancy and Health Program

By asking if 1) the individual ever consumes By asking if 1) the individual ever consumes five or more drinks on any occasion, and 2) if five or more drinks on any occasion, and 2) if she ever feels that she should cut down on she ever feels that she should cut down on drinking, clinicians could detect 92% of the drinking, clinicians could detect 92% of the women identified as being at genuine risk by women identified as being at genuine risk by the intervention interview.the intervention interview.

--Streissguth, 1997--Streissguth, 1997

Pregnancy and Health Program Pregnancy and Health Program Intervention ProcedureIntervention Procedure

• Provide Information on Alcohol and PregnancyProvide Information on Alcohol and Pregnancy

• Recommend Abstaining from Alcohol Recommend Abstaining from Alcohol during the remainder of the pregnancyduring the remainder of the pregnancy

• Help Each Woman Work Out an Help Each Woman Work Out an Individual Plan of ActionIndividual Plan of Action

--Streissguth, 1997--Streissguth, 1997

Developing an Action Plan with the Pregnant PatientDeveloping an Action Plan with the Pregnant Patient

• ““Do you need help with your drinking”Do you need help with your drinking”

• ““In what sorts of situations are you likely to drink?”In what sorts of situations are you likely to drink?”

• ““I don’t want you to drink. It matters to me. Your I don’t want you to drink. It matters to me. Your child matters to me.”child matters to me.”

• ““When is it hardest for you not to drink?”When is it hardest for you not to drink?”

• NEVER: “One drink a day probably won’t hurt.”NEVER: “One drink a day probably won’t hurt.”

• This is not reinstating “prohibition.” There are This is not reinstating “prohibition.” There are legitimate, legitimate, scientifically-based reasonsscientifically-based reasons not to drink not to drink when pregnant.when pregnant.

Developing an Action Plan with the Pregnant PatientDeveloping an Action Plan with the Pregnant Patient

Assuming a clear, credible decision is made not to drink:Assuming a clear, credible decision is made not to drink:

• ““The only clear limit for number of drinks per day is none.”The only clear limit for number of drinks per day is none.”

If the patient resists eliminating alcohol consumption entirely:If the patient resists eliminating alcohol consumption entirely:

• ““How much can you cut down by the next time you see me”How much can you cut down by the next time you see me”

• ““What can you do to reduce your drinking?”What can you do to reduce your drinking?”

The goal is to minimize drinking if it cannot be eliminated and toThe goal is to minimize drinking if it cannot be eliminated and toavoid multiple drink situations likely to yield high peak bloodavoid multiple drink situations likely to yield high peak bloodalcohol levels. Try to work with pt to restructure behaviors, e.g..alcohol levels. Try to work with pt to restructure behaviors, e.g..not going out with friends on Friday night after work.not going out with friends on Friday night after work.

BEHAVIORAL intervention by Physicians offers one of the best

hopes for reducing the largest source of mental retardation and

developmental delay

What if the patient won’t stop drinking?What if the patient won’t stop drinking?

• Alcohol treatment center referralAlcohol treatment center referral(e.g., Prarie Center, New Choice, Mental Health)(e.g., Prarie Center, New Choice, Mental Health)

• If beyond the point of probable serious damage,If beyond the point of probable serious damage,““There is a set of options. I cannot recommendThere is a set of options. I cannot recommendany particular one, but I can discuss them allany particular one, but I can discuss them allwith you. Here is where your child may stand.”with you. Here is where your child may stand.”(In this context, pregnancy termination is an(In this context, pregnancy termination is an option.)option.)

Rehabilitation ConditionRehabilitation Condition

Inactive ConditionInactive Condition