Dr. Jaimie St. Ama

1. The Impact of Parental Substance Abuse on Children at Various Developmental Periods & Effective Treatment Interventions Dr. Jaimie St. Ama

2. Jaimie St. Ama, Psy.D. www.pbbhw.com (561) 429-2397

3. Objectives • Learn to define and develop an understanding of epigenetics and the impact of in utero exposure to drugs. • Develop an understanding of the subsequent learning and behavioral challenges associated with epigenetics influence at different developmental periods. • Learn strategies to reduce the impact of epigenetics. • Learn interventions to address challenges of substance exposure at every developmental stage.

5. What is Epigenetics? • Epigenetics literally means “in addition to changes in genetic sequence.” • Processes that alter gene activity without changing the DNA sequence. • Changes in individual caused by modifications of gene expression that DOES NOT alter genetic code.

6. Genetics

7. Epigenetics • Affects how genes are read by cells and how they produce proteins, which control life functions (emotional, behavioral, social, physical, adaptive) • Epigenetics controls genes- can turn them off or turn them on over time • Everything we do affects genes- sleep schedule, eating habits, exercise, and aging • Genes can have normal/healthy/adaptive or dysfunctional/unhealthy/maladaptive state • Likewise gene modification can be healthy or unhealthy • Changes in gene expression causes unique differences • We can impact epigenetics both positively and negatively

8. Epigenetic Influences • In utero exposure to teratogens, stress, trauma, poverty, oppression • Teratogen= an agent and factor that causes malformation of an embryo • Examples include radiation, maternal infections, chemicals, drugs, pollution, alcohol, nicotine, medications • Parental mental health • Parental physical health • Parental behavioral problems • Parental addiction

9. Imprinting and Epigenetic Inheritance • We used to believe when sperm fertilized egg the DNA from one parent was erased to create a clean slate for the development of the infant. • Research discovered in mammals DNA from mother and father is not silenced and instead imprinted genes are passed on to the infant • These epigenetic tags are carried on and impact development and functioning • Epigenetics tags= parents’ experiences • 1% of genes can escape epigenetic reprogramming= imprinting

10. 5.9% of pregnant women abuse illicit substances despite prevention and education programs. Substance Abuse and Mental Health Services Administration, 2013

11. The number of women with opioid use disorder at labor and delivery quadrupled from 1999-2014.

12. Opioid Stats Among 28 states with public data from the 1999-2013 longitudinal study by State Inpatient Databases of the Healthcare Cost and Utilization Project (HCUP) found infants who suffered opioid withdrawal upon birth increased by 300% by 2013.

13. Neonatal Abstinence Syndrome (NAS) Symptoms: Blotchy skin coloring Diarrhea Excessive or high pitched crying Fever Increased heart rate Irritability Feeding problems Sleep problems Rapid breathing Seizures Slow weight gain Trembling Vomiting • NAS describes an infant’s symptoms of withdrawal after birth when a pregnant mother abuses opioids, alcohol, caffeine, and sedatives. • The type and severity of withdrawal symptoms is based on substances used, duration and frequency of use, how mother metabolizes and breaks down the substance, and if the baby was born at full-term or prematurely.

14. In Utero Exposure to Drugs Challenges • Premature birth • Developmental delays • Sudden infant death syndrome (SIDS) • Mental health problems • Behavioral and emotional difficulties • Social difficulties • Physical growth • Physical problems • IQ and academic functioning • Executive functioning difficulties • Addiction problems

15. Arousal ParadigmThe Yerkes-Dodson Curve

16. Arousal Characteristics Under Arousal Over Arousal Impulsive Racing mind Hyperactive Teeth grinding Sensory overload Difficulty falling asleep • Inattention • Low energy • Distractibility • Forgetfulness • Depression • Low self-esteem

18. Erikson’s Stages Psychosocial Development

19. Erikson’s Stages of Development 101 • 8 stages of psychosocial development created by Erik Erikson to address personality development from infancy to late adulthood. • Each stage acts as a series of events that an individual must move through to develop a certain virtue. • Infancy- Basic Trust vs. Mistrust (Hope) • Toddler- Autonomy vs. Shame (Will) • Preschool- Initiative vs. Guilt (Purpose) • School Age- Industry vs. Inferiority (Competence) • Adolescence- Identity vs. Role Confusion (Fidelity) • Young Adult- Intimacy vs. Isolation (Love) • Middle Age Adult- Generativity vs. Self absorption or Stagnation (Care) • Late Adult- Integrity vs. Despair (Wisdom)

22. Erikson’s Stages of Development • Stage 1. Infancy- Birth to 18 months • Learning to trust the world around them (Trust vs. Mistrust) • Feeding • Motor skills develop • Independent sitting • Walking • Play development • Learning through others, play, and exploration while feeling safe • Personality starts to develop- interests • Trust vs. Mistrust Stage- infants learn to trust by caregivers. If needs are met, a sense of trust is established but if needs are not met, mistrust manifests.

23. Challenges from in utero exposure to substances • Feeding delays, picky eating, food aversions • Motor skill delay, coordination difficulties • Lack of imaginary play, difficulty playing with others • Impaired interpersonal relationships • Inability to trust others • Stronger independent skills out of necessity • Cognitive delays • Personality problems- more dependent, less independent, strong willed, anxious

24. Interventions for Stage 1 • Multiple team approach- medical, mental health, occupational, behavioral, and specialists • Play therapy and ABA therapy • Attachment • Parent-Child Interaction Therapy- teaching healthy responses to infant • Florida’s Early Steps System- assessment, interventions, programs, coordination • http://www.floridahealth.gov/alternatesites/cms-kids/families/early_steps/early_steps.html

25. Erikson’s Stages of Development Stage 2. Early Childhood/ Toddler (2-3 years old) • Autonomy vs. Shame/Doubt- working to establish independence • Building self-esteem and beginning stages of their sense of identity • Toilet training • Speech develops and starts to become more complex • Using utensils and feeding skills improve • Stamina and prolonged attention to task • Motor skills become more precise- kicking, throwing, catching • Fine motor skills improve- copying a line, cutting with scissors, • Can resist impulsivity and delay gratification more • Empathy and perspective taking abilities • Mathematical skills • Vocabulary increases and understanding of grammatical rules • Memory increases

26. Challenges to Development During Stage 2 • Delayed toilet training and more accidents (enuresis and encopresis) • Speech problems • Low adaptive skills • Delayed and impaired working memory developing • Fine and gross motor skill delays • Impulsivity • Executive functioning problems • Low empathy • Low self-esteem and resilience needed to explore world (Scared) • Impaired social skills • Separation anxiety

27. Effective Interventions For Stage 2 • Speech therapy • Behavior and play therapy • Medical interventions to address toileting, encopresis, and enuresis • Social skills groups • Guided play • Occupational therapy • Foster independence, building of self-esteem, and resilience through safely exploring environment • Teach caregiver to meet needs

28. Erikson’s Stages of Development • Stage 3. Preschool 3- 6 years old • Initiative vs. Guilt- learning to plan and achieve goals while interacting with others. Children look to be more ambitious and responsible through exploration with limits and boundaries. • Self-confidence, independence, and self-esteem increases • Gross motor- Coordination and balance improves • Fine motor refines- handwriting starts to develop, buttoning and unbuttoning • Greater understanding of past, present, and future • Problem solving skills • Reading skills develop • Appreciation of humor and jokes • Independent dressing • Detailed drawing • Abstract thinking starts to develop • Distinguish between reality and fantasy • Start differentiating friends based on personality, interests, and interactions • Tying shoes

29. Challenges from In Utero Exposure During Stage 3 • Impaired self-esteem, confidence, and difficulty achieving goals • Lack of independence • Emotional problems • Gross and Fine motor problems • Impaired problem-solving ability • Stuck in the now • Difficulty reading and delayed reading skills • Difficulty with abstract thinking skills • Impaired social skills- intrusive or avoiding • Neurological problems • Difficulty differentiating between reality and fantasy • Impaired sense of humor

30. Interventions for Stage 3 • Establishing sense of self and independence through achievement of small and concise goals • Occupational therapy • Engagement in sports and activities to improve gross motor skills • Art therapy- formal or informal with crafts • Problem-solving improvement through games like Clue, questioning such as what happened before, and what could happen next • Practice with reading • Psychological testing • Social skills groups • Academic interventions • Teaching time and place, the power of jokes, and reality vs. fantasy • STEM projects

31. Erikson’s Stages of Development • Stage 4. School Age 6-11 years old. • Industry vs. Inferiority- comparison to peers to evaluate sense of self and worth • Bodily awareness • Seeking privacy when naked • Appetite changes • Testing of limits with physical behavior • Sleep problems as growth changes • Abstract thinking increases • Ability to self-evaluate • Fears develop • Self-image and body image awareness • Permanent teeth come in • Improved peripheral vision • Figurative speech • Conscious awareness • Growth spurts- prepuberty • Awareness of time • Empathy improves • Weight changes • Speech improves to add conversational ability • Puberty can start • Moral reasoning

32. Challenges created by In Utero Exposure at Stage 4 • Low self-worth, disbelief in abilities • Dissociative from body • Lack of boundaries or avoidance of social input • Gain or lose weight excessively • Delayed moral reasoning, consciousness • Time management problems • Executive functioning difficulties • Acting out sexually • Emotional problems • Sleep problems- difficulty with falling and staying asleep and nightmares • Inability to self-evaluate or recognize strengths and limitations • Difficulty with abstract thinking • Self-harming behaviors • Weak or overly aggressive • Speech/ communication problems • Phobic fears, OCD type thoughts, and difficulty embracing world • Delayed growth and puberty

33. Interventions for Stage 4 • Individual, group, and family therapy • Teaching time and place • Teaching nutrition and healthy eating strategies- mind, body, and soul connection • Moral reasoning strategies • Executive functioning coaching • Self-esteem strategies- finding talent • Teaching strategies to understand/recognize strengths and limitations • School interventions • Mindfulness • Neurofeedback • Speech therapy • Medical interventions • Psychopharmacology • Sports, CrossFit for kids, or martial arts • Teaching healthy coping skills

34. Erikson’s Stages of Development • Stage 5. Adolescence 12-18 years old. • Identity vs. Role Confusion- development of a sense of self and finding morals, talents, strengths, values, limitations, and interests through exploration and comparison • Puberty • Moral reasoning continues and evolves • Friends become more important than familial relationships • Connections through talking increase in importance • Greater awareness of fitting in/ being influenced by environment • Sleep changes and difficulty • Weight changes with more awareness and feeling uncomfortable with changes • Sexuality becomes a factor • Critical thinking skills enhanced • Abstract thinking skills • Meta-cognition- “knowing about knowing”- teens are able to think about and analyze their feelings and determine how others see them • Testing of limits as identity forms • Sense of justice about important events in the world- see the bigger picture • Intimate relationships • Distance from parents

35. Challenges at Stage 5 • Lack of identity/ false sense of self/ acclimating to a group without a real connection • Delayed puberty • Difficulty with moral reasoning • Impaired social skills and difficulty with connection- withdrawal or over reliance on friendships • Lack of social/ emotional awareness of self or others • Overly sexualized and disinterest • Substance abuse • Legal problems • Impaired communication skills • Difficulty seeing the bigger picture, not connected to world • Overly reliant on parents/ low adaptive skills and independence • Impaired abstract thinking/ critical thinking • Insomnia, excessive sleep • Mental health diagnoses more evident • Personality problems manifest • Emotional dysregulation • Academic problems

36. Effective Interventions Stage 5 • Individual, group, and family therapy • Identity building exercises • Medical approaches • Time and place and education about sexual behaviors • Foster independence through chores, challenges, and responsibility • Activities to engage in greater good and understanding bigger picture connection • Healthy coping skills • Substance abuse treatment and education • Sleep hygiene and education • Critical thinking strategies • Residential treatment • Psychopharmacology • School interventions • Neurofeedback

37. References Andersen, S. L. (2003). Trajectories of brain development: point of vulnerability or window of opportunity? Neuroscience and Biobehavioral Reviews, 27(1-2), 3-18. Bergman, K., Sarkar, P., Glover, V., & O'Connor, T. G. (2010). Maternal prenatal cortisol and infant cognitive development: Moderation by infant-mother attachment. Biological Psychiatry, 67(11), 1026–1032. Bowdin, S. et al. (2007). A survey of assisted reproductive technology births and imprinting disorders. Human Reproduction, 22 (12): 3237-3240. Bouchard, T.J. (1994, June). Genes, environment, and personality. Science, 264. British Neuroscience Association. (2013, April 7). Fetal exposure to excessive stress hormones in the womb linked to adult mood disorders. ScienceDaily. Retrieved October 16, 2017 from www.sciencedaily.com/releases/2013/04/130407090835.htm Bruce, J., Gunnar, M. R., Pears, K.C., and Fisher, P.A. (2013). Early adverse care, stress neurobiology, and prevention science: Lessons learned. Prevention Science 14(3), 247-256. Buss, C., Davis, E. P., Muftuler, L. T., Head, K., & Sandman, C. A. (2010). High pregnancy anxiety during mid-gestation is associated with decreased gray matter density in 6-9-year-old children. Psychoneuroendocrinology, 35(1), 141–153. Buss, C., Davis, E. P., Hobel, C. J., & Sandman, C. A. (2011). Maternal pregnancy-specific anxiety is associated with child executive function at 6-9 years age. Stress, 14(6), 665–676 Buss, C., Entringer, S., Reyes, J. F., Chicz-Demet, A., Sandman, C. A., Waffarn, F., & Wadhwa, P. D. (2009). The maternal cortisol awakening response in human pregnancy is associated with the length of gestation. American Journal of Obstetrics and Gynecology, 201(4), 398.e391–398 Connors, S. L., Levitt, P., Matthews, S.G., Slotkin, T.A., Johnson, M.V., Kinney, H.C.,…Zimmerman, A.W. (2008). Fetal mechanisms in neurodevelopmental disorders. Pediatric Neurology, 38(3), 163-176. Davis, E.P. and Sandman, C.A. (2010). The timing of prenatal exposure to maternal cortisol and psychosocial stress is associated with human and infant cognitive development. Child Development, 81(1), 131-148. Davis, E. P., Glynn, L. M., Schetter, C. D., Hobel, C., Chicz-Demet, A., & Sandman, C. A. (2007). Prenatal exposure to maternal depression and cortisol influences infant temperament. Journal of the American Academy of Child and Adolescent Psychiatry, 46(6), 737–746.

38. References Egger, G., et al. Epigenetics in human disease and prospects for epigenetic therapy. Nature429, 457–463 (2004) doi:10.1038/nature02625 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. Forray, A. (2016). Substance use during pregnancy. Version 1. F1000Res. 2016; 5: F1000 Faculty Rev-887. Huestis, M.A. et al. (2002). Drug abuse’s smallest victims: in utero drug exposure. Forensic Science International , Volume 128 , Issue 1 , 20 - 30 Ko J.Y., Patrick S.W., Tong V.T., Patel R., Lind J.N., Barfield W.D. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. MMWR Morb Mortal Wkly Rep 2016;65:799–802. DOI: http://dx.doi.org/10.15585/mmwr.mm6531a2. Pechtel, P., & Pizzagalli, D. A. (2011). Effects of early life stress on cognitive and affective function: an integrated review of human literature. Psychopharmacology, 214(1), 55–70. Psychology Encyclopedia (2017). Nature-Nurture Controversy. Genes and Behavior, 1106-1138. Ross, E.J., Graham, D.L., Money, K.M. and Stanwood, G.D. (2015). Developmental consequences of fetal exposure to drugs: What we know and what we still must learn. Neuropsychopharmacology. 2015 Jan; 40(1): 61–87. Simmons, D. (2008) Epigenetic influence and disease. Nature Education 1(1):6 Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016. Swanson, J.M. & Wadhwa, P.D. (2008). Developmental origins of child mental health disorders. Journal of Child Psychology and Psychiatry and Allied Disciplines, 49(10), 1009-1019. van der Kolk BA. (2003). The neurobiology of childhood trauma and abuse. Child AdolescPsychiatric Clin N Am. 12: 293-317. van der Kolk, BA, Roth S, Pelcovitz D, Mandel FS, Spinazzola J. (2005). Disorders of Extreme Stress: the empirical foundation of a complex adaptation to trauma. J Trauma Stress. Weinhold, B. (2006). Epigenetics. Environmental Health Perspectives 114(3).