Fetal Alcohol Spectrum Disorder: Assessment & Strategies

1. Fetal Alcohol Spectrum Disorder: Assessment & Strategies Stade 2008 www.faseout.ca

2. Outline • Introduction • Early Identification and Assessment • Diagnostic guidelines and assessment • Screening • Rational for early diagnosis • Cognitive, Behavioral, Social Development and Nutrition of Children, Birth to Age 6 years • Issues and Strategies • Focus on Families Stade 2008 www.faseout.ca

3. Introduction • In Canada the incidence of Fetal Alcohol Spectrum Disorder (FASD) has been estimated to be 1 in 100 live births. Stade 2008 www.faseout.ca

4. Introduction • Caused by prenatal exposure to alcohol. • FASD is the leading cause of developmental and cognitive disabilities among Canadian children. Stade 2008 www.faseout.ca

5. Introduction: Fetal Alcohol Spectrum Disorder Defined • Growth Restriction • Facial Anomalies • CNS Dysfunction • Prenatal Alcohol Exposure Stade 2008 www.faseout.ca

6. Introduction • Cost of FASD annually to Canada of those 1 to 21 years old, was $344,208,000 (95% CI $311,664,000; $376,752,000). • (Stade, 2004). Stade 2008 www.faseout.ca

7. Introduction: 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 Stade 2008 www.faseout.ca

8. 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. Stade 2008 www.faseout.ca

9. 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 standard drinks per week (1 standard drink = 13.6 grams of absolute alcohol). • Binge drinking of more than 5 ounces (142 grams) per occasion vs. 4 or more drinks per occasion. Stade 2008 www.faseout.ca

10. Standard drinks = 0.5 oz alcohol 12 oz (341 mL) can of beer (5% alcohol) 12 oz (341 mL) bottle of cooler (5% alcohol) 5 oz (142 mL) glass of wine (12% alcohol) 1.5 oz (43 mL) distilled spirits (40% alcohol) 3 oz (85 mL) fortified wine e.g. sherry or port (18% alcohol ) Stade 2008 www.faseout.ca

11. Etiology • No safe time to drink during pregnancy • No known safe amount Stade 2008 www.faseout.ca

12. Risk Factors • Maternal Age and Parity • Chronicity of Alcoholism • Socioeconomic Status • Polydrug Use • Ethnicity • Fetal Susceptibility Stade 2008 www.faseout.ca

13. Diagnostic Guidelines Stade 2008 www.faseout.ca

14. Important Features of Diagnostic Guidelines • Minimize false negatives and false positives • Precisely define diagnostic criteria • Consider genetic and family histories • Multidisciplinary approach Stade 2008 www.faseout.ca

15. Rational for Early Diagnosis • Accurate and timely diagnosis is essential: • to improve outcomes • decrease risk of secondary disabilities • increase opportunities for prevention • ensure more accurate estimates of incidence and prevalence Stade 2008 www.faseout.ca

16. Canadian Guidelines for Diagnosis CMAJ, March 2005 • The Diagnostic Process • Screening and referral • Physical exam and differential diagnosis • Neurobehavioural assessment • Treatment and follow-up • Team members • Program director/Co-ordinator • Physician (trained in diagnosis) • Psychologist • Social worker • OT, Speech, psychiatrist, geneticist, addiction worker, community support workers, teachers etc. Stade 2008 www.faseout.ca

17. Canadian Guidelines for Diagnosis • Physical Exam • General physical to rule out other disorders • Growth (at or below 10th percentile) • Facial features Stade 2008 www.faseout.ca

18. Growth Restriction • Growth restriction is demonstrated by height and weight at or below the tenth (10th) percentile • Growth restriction may be apparent prenatally and/or postnatally Stade 2008 www.faseout.ca

19. Facial Features • Short palpebral fissures • Smooth or flat philtrum • Thin upper lip Stade 2008 www.faseout.ca

20. Facial Features Stade 2008 www.faseout.ca

21. Associated Anomalies • Cardiac anomalies • Joint and limb anomalies • Neurotubal defects • Anomalies of the urogenital system • Hearing disorders • Visual problems • Severe dental malocclusions Stade 2008 www.faseout.ca

22. Canadian Guidelines for Diagnosis-Neuro-behavioural Assessment • Domains to be assessed by psychologist or team: • Hard and soft neurological signs • Brain structure • Cognition (IQ) • Communication • Academic achievement • Memory • Executive functioning • Attention deficit/hyperactivity • Adaptive behaviour, social skills, social communication Stade 2008 www.faseout.ca

23. Early Infancy • Tremors • Poor suck • Hypotonic/Hypertonic • Irritability • Feeding problems • Developmental delay Stade 2008 www.faseout.ca

24. Cognitive Problems Motor Issues Behavioral Presentation Sensory Dysfunction Speech Delay Hyperactivity Socialization Difficulties Early Childhood Stade 2008 www.faseout.ca

25. Canadian Guidelines for DiagnosisMaternal Alcohol History in Pregnancy • Key to establishing an accurate diagnosis • Require confirmation based on clinical records, self-report, reliable observation Stade 2008 www.faseout.ca

26. Classification of FASD • Fetal Alcohol Syndrome (FAS) • Partial Fetal Alcohol Syndrome (PFAS) with confirmed maternal alcohol exposure • Alcohol-Related Neuro-Developmental Disorder (ARND) with confirmed maternal alcohol exposure Stade 2008 www.faseout.ca

27. Diagnostic Criteria FAS • Evidence of growth impairment • 3 facial anomalies • 3 central nervous system domains impaired • Confirmed or unconfirmed alcohol exposure Stade 2008 www.faseout.ca

28. Diagnostic Criteria Partial FAS • 2 facial anomalies • 3 central nervous system domains impaired • Confirmed alcohol exposure. Stade 2008 www.faseout.ca

29. Diagnostic Criteria ARND • 3 central nervous system domains impaired • Confirmed alcohol exposure. Stade 2008 www.faseout.ca

30. Screening Stade 2008 www.faseout.ca

31. Screening and Primary Care Referral Referral of individuals to FASD diagnostic clinics: • Evidence of prenatal exposure to alcohol (or probable) with suspected or confirmed CNS dysfunction or • Presence of 3 characteristic facial features with growth deficits with or without known prenatal alcohol exposure. Stade 2008 www.faseout.ca

32. Conclusion • Diagnosis requires a multi-disciplinary approach • Diagnosis is complex and guidelines are well defined and cannot be a gestalt approach • Confirmed prenatal alcohol exposure is required for a diagnosis of Partial FAS and ARND • Screening does not equate to diagnosis. Stade 2008 www.faseout.ca

33. Cognitive, Behavioral, Social Development and Nutrition of Children from Birth to Age 6 Stade 2008 www.faseout.ca

34. Cognitive Stade 2008 www.faseout.ca

35. Cognition • Attention problems and memory deficits often make learning difficult in the young child. Stade 2008 www.faseout.ca

36. Cognition • Infants and young children with FASD live with differing levels of cognitive abilities • All programs to develop cognitive abilities should be child specific. Stade 2008 www.faseout.ca

37. Cognition • How does the individual child with FASD learn? Some are primarily visual learners, some are tactile learners, some kinesthetic, and some learn best by listening. (Mountford,A. The Golden Hoop of Life). Stade 2008 www.faseout.ca

38. Cognition: Strategies • If a child learns best through music … • If a child learns through body movement … • If a child learns best through listening … • If a child is a tactile learner … (Mountford, A. The Golden Hoop of Life). Stade 2008 www.faseout.ca

39. Cognition: Strategies • May need to use short sentences • Break down information and instruction • Repetition, Repetition, Repetition • Teach one concept at a time. Stade 2008 www.faseout.ca

40. Cognition: Strategies • “ It took him four weeks at age four to learn the colour red. We decided in February he was going to learn his colours. So everyday of the month I dressed him in red. The teacher had to say ‘X you’re wearing a red shirt today. Show me your shirt. It’s red’. ‘X you’re wearing red pants today’. Something had to be red”. Stade 2008 www.faseout.ca

41. Cognition: Strategies • Treasure hunts • Problem-solving activities • Visual-spatial games • Story building • Math skills: visual teaching Stade 2008 www.faseout.ca

42. Cognition Impacting on the development of cognitive skills is the child’s ability to process their sensory world. Stade 2008 www.faseout.ca

43. Sensitivity Stade 2008 www.faseout.ca

44. Sensory Processing Many infants and young children with FASD have difficulty processing and organizing sensory information they receive from their own bodies and the outside world. Stade 2008 www.faseout.ca

45. Sensory Processing • Sensory processing is a developmental process • Takes place in the central nervous system • Involves ability to take in information through the senses, organize it in our brains and use it to respond appropriately Stade 2008 www.faseout.ca

46. Sensory Processing The brain must properly process information from the senses to develop: • concentration • organization • learning ability • specialization of each side of the body and brain • self-esteem • self-control Stade 2008 www.faseout.ca

47. Sensory Processing How does sensory processing abilities impact on day-to-day life of a child with FASD? Stade 2008 www.faseout.ca

48. Normal Sensory Integration • Schwab, D. (2001). Stade 2008 www.faseout.ca

49. Sensory Processing • Hypersensitive • Touch (Touch Processing) • Noise (Auditory Processing • Visual Input (Visual Processing). • Dysfunction in Behavioural Outcomes of Sensory Processing. Stade 2008 www.faseout.ca

50. Sensory Processing Strategies • Place your child first or last in line • Wash clothes a couple of times before wearing • Use soft bedding • Remove tags from clothes • Avoid: • ties under the chin • thick seams in clothing • clothes that are scratchy • Avoid tickling Stade 2008 www.faseout.ca