Fetal

Alcohol

Syndrome

Manish Saran MD

Department of Psychiatry

Louisiana State University Health Sciences Center Shreveport

February 8, 2006

Historical view of alcohol as a Historical view of alcohol as a teratogenteratogen

Foolish, drunken, or Foolish, drunken, or harebrain women harebrain women most often bring forth most often bring forth children like unto children like unto themselves themselves Aristotle in Aristotle in ProblemataProblemata

Behold, thou shalt Behold, thou shalt conceive and bear a conceive and bear a son: And now, drink son: And now, drink no wine or strong no wine or strong drink.drink.

Judges 13:7Judges 13:7

Some Facts Some Facts

60% of adult women drink 60% of adult women drink 4% abuse or are dependent4% abuse or are dependent 20% of pregnant women drink 20% of pregnant women drink

3% heavy drinkers3% heavy drinkers 5.5% illegal drugs, 0.9%cocaine5.5% illegal drugs, 0.9%cocaine

Fetal alcohol syndrome Fetal alcohol syndrome

FAS is a developmental disability caused by FAS is a developmental disability caused by prenatal exposure to high levels of ETOHprenatal exposure to high levels of ETOH

Most common preventable cause of adverse Most common preventable cause of adverse CNS developmentCNS development

The reported prevalence of the disorder varies The reported prevalence of the disorder varies widely, estimates approach 1% of live birthswidely, estimates approach 1% of live births

4,000-12,000 infants per year in US4,000-12,000 infants per year in US The disorder is identified by the presence of The disorder is identified by the presence of

growth impairment, central nervous system growth impairment, central nervous system dysfunction, and a characteristic pattern of dysfunction, and a characteristic pattern of craniofacial features craniofacial features

Facies in Fetal Alcohol SyndromeFacies in Fetal Alcohol Syndrome

Adult FaciesAdult Facies

Fetal Alcohol EffectsFetal Alcohol Effects

Only a minority (10-40%) of the children of Only a minority (10-40%) of the children of chronic alcoholic women are diagnosed with chronic alcoholic women are diagnosed with FASFAS

Fetal Alcohol Effects (FAE): individuals lack the Fetal Alcohol Effects (FAE): individuals lack the outward physical appearance of alcohol outward physical appearance of alcohol damage, and generally have higher IQ'sdamage, and generally have higher IQ's

7,000-36,000 infants per year in US The internal damage to the brain and other The internal damage to the brain and other

organs can be just as seriousorgans can be just as serious

Fetal Alcohol Spectrum DisordersFetal Alcohol Spectrum Disorders

category 1 FAS with confirmed maternal ETOH category 1 FAS with confirmed maternal ETOH exposureexposure

category 2 FAS without confirmed maternal category 2 FAS without confirmed maternal ETOH exposureETOH exposure

category 3 partial  FAS with confirmed maternal category 3 partial  FAS with confirmed maternal ETOH exposureETOH exposure

category 4 ARBD (alcohol -related birth defects), category 4 ARBD (alcohol -related birth defects), (physical only)(physical only)

category 5 ARND (alcohol -related category 5 ARND (alcohol -related neurodevelopmental disorder) neurodevelopmental disorder)

Co morbid ConditionsCo morbid Conditions

attention deficit hyperactivity disorder attention deficit hyperactivity disorder (40%)(40%)

mental retardation (15–20%) mental retardation (15–20%) learning disorders (25%)learning disorders (25%) speech and language disorders (30%), speech and language disorders (30%),

sensory impairment (30%) sensory impairment (30%) cerebral palsy (4%)cerebral palsy (4%) epilepsy (8–10%). epilepsy (8–10%).

Brain damageBrain damageThe brain on the right suffers from microencephaly and migration anomalies (neural and glia cells did not migrate to their proper location in the brain, but instead many of them simply migrated to the top of the cortex). Although it cannot be seen here, there is also agenesis of the corpus callosum and the ventricles are dilated.

General Intellectual PerformanceGeneral Intellectual Performance

FSIQ VIQ PIQ40

55

70

85

100

115S

tan

dar

d s

core

IQ scale

**

*

**

**

Prenatal Exposureto Alcohol

Fetal Alcohol Syndrome

Normal control

Neuropsychological PerformanceNeuropsychological Performance

FSIQ Read Spell Arith PPVT BNT ATotal VMI PegsD CCT40

50

60

70

80

90

100

110

120

Measure

CON

PEA

FAS

2

1

3

1

2

3

Group0

2

4

6

Ru

le V

iola

tio

ns

NC

PEA

FAS

P<0.001

Move only one piece at a time using one hand and never place a big piece on top of a little piece

Starting position

Ending positionMattson, et al., 1999

Executive functioning deficitsExecutive functioning deficits

Secondary DisabilitiesSecondary Disabilities

Risk FactorsRisk Factors

Dose of alcoholDose of alcohol the higher the dose of alcohol, the greater the the higher the dose of alcohol, the greater the

likelihood that the child will exhibit fetal alcohol effectslikelihood that the child will exhibit fetal alcohol effects Pattern of exposure - binge vs chronicPattern of exposure - binge vs chronic

Both human and animal studies have found that binge Both human and animal studies have found that binge drinking (drinking a large amount of alcohol in a short drinking (drinking a large amount of alcohol in a short period of time), which produces high blood alcohol period of time), which produces high blood alcohol levels, is more damaging to the fetus than chronic levels, is more damaging to the fetus than chronic alcohol exposure that produces lower blood alcohol alcohol exposure that produces lower blood alcohol levels.levels.

Risk FactorsRisk Factors

Developmental timing of exposureDevelopmental timing of exposure the facial features associated with prenatal alcohol the facial features associated with prenatal alcohol

treatment appear to be related to alcohol exposure treatment appear to be related to alcohol exposure during the first trimesterduring the first trimester

The brain undergoes a very prolonged developmental The brain undergoes a very prolonged developmental course and therefore, may be susceptible to fetal course and therefore, may be susceptible to fetal alcohol effects throughout gestationalcohol effects throughout gestation

Genetic variationGenetic variation Maternal characteristicsMaternal characteristics Synergistic reactions with other drugsSynergistic reactions with other drugs NutritionNutrition

Treatment and PreventionTreatment and Prevention

Very little research done on these topicsVery little research done on these topics Many children with FAS treated for their Many children with FAS treated for their

individual symptoms (e.g. stimulants for ADHD)individual symptoms (e.g. stimulants for ADHD) Animal data indicates that early intervention with Animal data indicates that early intervention with

environmental variables might have a beneficial environmental variables might have a beneficial effect such as effect such as motor training motor training

Public education may not be reaching the Public education may not be reaching the women most likely to have a child with FASwomen most likely to have a child with FAS

Intensive, case-management approaches Intensive, case-management approaches appear to work very well.appear to work very well.

Prevention – The Birth to 3 ProgramPrevention – The Birth to 3 Program

Parent-child assistance programParent-child assistance program Intensive home visitation model for the highest risk mothersIntensive home visitation model for the highest risk mothers Paraprofessional AdvocatesParaprofessional Advocates Paired with client for 3 years following the birth of the target Paired with client for 3 years following the birth of the target

BabyBaby Link clients with community servicesLink clients with community services Extensively trained and closely supervisedExtensively trained and closely supervised Maximum caseload of 15Maximum caseload of 15

OutcomesOutcomes Fewer alcohol/drug affected childrenFewer alcohol/drug affected children Reduced foster care placementReduced foster care placement Reduced dependence on welfareReduced dependence on welfare

Ethnic ConsiderationsEthnic Considerations

Rate of FAS (per 1000; 1980-1986)Rate of FAS (per 1000; 1980-1986) Native Americans 2.97Native Americans 2.97 African Americans 0.6African Americans 0.6 Caucasians 0.09Caucasians 0.09 Hispanics 0.08Hispanics 0.08 Asians 0.03Asians 0.03

SummarySummary

Fetal Alcohol Syndrome is a devastating developmental Fetal Alcohol Syndrome is a devastating developmental disorder that affects children born to women who abuse disorder that affects children born to women who abuse alcohol during pregnancy.alcohol during pregnancy.

Although FAS is entirely preventable, and in spite of our Although FAS is entirely preventable, and in spite of our increasing knowledge about the effects of prenatal increasing knowledge about the effects of prenatal alcohol exposure, children continue to be born exposed alcohol exposure, children continue to be born exposed to high amounts of alcohol.to high amounts of alcohol.

Its consequences affect the individual, the family, and Its consequences affect the individual, the family, and society.society.

Its costs are tremendous, both personally and financially.Its costs are tremendous, both personally and financially. Effective treatment and prevention strategies must be Effective treatment and prevention strategies must be

developed and made available.developed and made available.

Discussion/Discussion/QuestionsQuestions