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Fetal Alcohol Syndrome Psychopathology 1 Master of Clinical Psychology Program 1

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1 Fetal Alcohol Syndrome Psychopathology 1 Master of Clinical Psychology Program 1 http://pernod-ricard.com/724/csr/responsible-drinking/pregnant-women

2 Doreen Canoy Email – d.canoy@cqu.edu.aud.canoy@cqu.edu.au 2

3 What is Fetal Alcohol Syndrome? Pattern of anomalies that have resulted due to prenatal exposure to alcohol – Facial anomalies – Growth retardation – Central nervous system dysfunction Recognised as being at the higher end on a continuum of disorders which can be attributed to prenatal alcohol exposure. 3 http://news.discovery.com

4 4 http://www.webjam.com/fas_supportjax

5 5 Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioural, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical diagnosis. (Bertrand et al., 2004, pp. 4)

6 Small size for age (especially as an infant) Facial abnormalities such as small eye openings Poor coordination Poor suck and sleep disturbances in infancy Hyperactive behaviour Learning disabilities Developmental disabilities (e.g. speech and language delays) 6 How would someone with FASD present?

7 Characteristics of FASD Con’t… Mental retardation or low IQ Poor reasoning and judgment skills Inconsistent or spotty memory Poor abstract thinking Impulsive and difficulty learning from mistakes Temper tantrum and difficulty with self control (not appropriate for age) 7

8 How is a diagnosis of FAS reached? 8 Patient General Practitioner PaediatricianPsychologist Social Worker PsychiatristNeurologist

9 Framework for FAS Diagnosis and Services Child presents for office visit – Triggers Emerge Complete initial evaluation to gather data related to FAS FAS Criteria NOT met – Continue to monitor changes in health over time. FAS Criteria Met - Refer to Specialist for further assessment FAS Diagnosis confirmed. Intervention plan is developed Intervention Plan is communicated to frontline providers 9 Source: Bertrand. J., Floyd, R.L., Weber, M.K., O'Connor, M., Riley, E.P., Johnson, K.A., Cohen, D.E., National Task Force on FAS/FAE. Fetal alcohol syndrome: Guidelines for referral and diagnosis. Atlanta, GA: Centers for Disease Control and Prevention; 2004, p.8. ​

10 Diagnostic Schemas 4-digit code / University of Washington National Task Force / The Centre for Disease Control and Prevention (CDC) Canadian Guidelines Revised Institute of Medicine (IOM) 10

11 All four schemas look to the three distinct areas – Prenatal and/or postnatal growth deficiency – Central nervous system dysfunction – Characteristic pattern of facial anomalies (differ on how many need to be present) 11 http://www.aafp.org/afp/2005/0715/p279.html www.come-over.to/FAS/FASbrain.htm Photo by Sterling Clarren, MD http://news.discovery.com

12 Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code (2004) Allows for a full assessment to be undertaken by a multi-disciplinary team of professionals The 4-Digit code of 4444 indicates a diagnosis of FAS, at the most extreme end of the FASD. Code of 1111 would indicate: – normal development, – no signs of facial deformities, – no CNS concerns and – no prenatal exposure to alcohol. This therefore allows for 256 Diagnostic Codes which can be logically grouped in 22 Diagnostic Categories 12

13 Physician – Sections pertaining to growth, structural & neurological measures of the CNS, facial features and other physical findings. Occupational Therapist, Psychologist, speech language pathologist and/or other team members complete sections pertaining to psychometric measures of CNS function. All members participate in the derivation of the 4-Digit Code and intervention plan. 13

14 Lets start at the beginning… 14 http://rffada.org/resources/researchhttp://rffada.org/resources/research - Russell Family Fetal Alcohol Disorders Association

15 Presenting symptoms of FAS Documentation of all three facial abnormalities – Smooth philtrum – Thin vermillion – Small palpebral fissures Documentation of growth deficits Documentation of Central Nervous System (CNS) abnormality 15 http://www.aafp.org/afp/2005/0715/p279.htmlhttp://www.aafp.org/afp/2005/0715/p279.html - Photograph

16 Facial Dysmorphia Based on racial norms Must exhibit all three characteristic facial features 16 http://www.come-over.to/FAS/WhoseBabyIsThis.htm

17 Smooth philtrum Thin vermillion border (University of Washington Lip-Philtrum Guide rank 4 or 5) 17 http://depts.washington.edu/fasdpn/htmls/lip-philtrum-guides.htm

18 18 Photo reprinted with permission from Susan Astley, University of Washington: www.fasdpn.org www.fasdpn.org

19 Small palpebral fissures – at or below 10 th percentile 19 Photo reprinted with permission from Susan Astley, University of Washington: www.fasdpn.org.www.fasdpn.org

20 20 http://m.medlineplus.gov/ency/imagepages/19842.htm

21 Growth Documentation of growth deficits: Confirmed prenatal or postnatal height or weight, or both, at or below the 10 th percentile, documented at any one point in time (adjusted for age, sex, gestational age, and race or ethnicity). Australasian Paediatric Endocrine Group Australian and New Zealand Growth Charts US Growth Charts (Centre for Disease Control) The WHO Child Growth Standards http://www.apeg.org.au/clinicalresourceslinks/growthgrowthcharts/tabid/101/default.aspx 21

22 Central Nervous System Structural – Head circumference at or below the 10 th percentile adjusted for age and sex – Clinically significant brain abnormalities observable through imaging. Neurological – Neurological problems not due to a postnatal insult or fever, or other soft neurological signs outside normal limits. Functional Global cognitive or intellectual deficits representing multiple domains of deficit (or significant developmental delay in younger children) – performance below the 3 rd percentile Functional deficits below the 16 th percentile (in at least three domains) See below for a table to assist with identifying Functional CNS deficits. Source: Adapted from Bertrand,J., Floyd, R. L., Weber, M. K., O'Connor, M., Riley, E. P.,Johnson, K. A., Cohen, D. E., & National Task Force on FAS/FAE. Fetal alcohol syndrome: Guideiines for referral and diagnosis. Atlanta, GA: Centers for Disease Control and Prevention;2004. 22 http://en.wikipedia.org/wiki/Human_brain

23 What does a healthy brain do? 23 http://alcoholpregnancy.childhealthresearch.org.au/about/fetal-alcohol- spectrum-disorders-(fasd).aspx

24 24 www.nofas.org

25 Comorbidity To increase the difficulty in achieving a correct diagnosis, a number of disorders are often comorbid with FAS. Autism Conduct Disorder (CD) Oppositional Defiant Disorder (ODD) Anxiety Disorders Adjustment Disorders Sleep Disorders Depression 25 http://allthingsd.com

26 26 FASD ADHD Set Shifting Complex Motor Skills Static Balance Social Skills Communication Skills Parent reports of behaviour Basic Motor Control Focused Attention Sustained Attention Retrieval Face & Emotion Processing Daily Living Skills Verbal Encoding Shifting Attention IQ Verbal Fluency Problem Solving Mattson, Crocker & Nguyen, 2011

27 Fetal Alcohol Syndrome Summary 100% Preventable 0% Curable BUT with early diagnosis and appropriate intervention individuals with FAS do have the potential to do well. Major Public Health Concern –vs- Moral Panic? 0.2 to 1.5 cases of FAS occur every 1,000 live births in USA. If FAS and ARND were added together – 9.1 cases for every 1,000 live births in USA. That would be nearly 1 in 100. 27 http://www.come-over.to/FAS/WhoseBabyIsThis.htm

28 Summary Con’t…. There is no biomarker for the diagnosis of Fetal Alcohol Syndrome. The effects of FAS may include physical, behavioural and/or learning difficulties. Comorbidity with a number of other disorders can complicate diagnosis. To ensure accurate diagnosis a Multidisciplinary Team approach is best. 28 http://pernod-ricard.com/724/csr/responsible-drinking/pregnant-women

29 References Armstrong, E. M., & Abel, E. L. (2000). Fetal alcohol syndrome: The origins of a moral panic. Alcohol & Alcoholism, 35(3), pp. 276-282. Astley, S. J. P. D. (2004). Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The four digit diagnostic code (Third ed., pp. 123). Seattle, WA: University of Washington. Bertrand, J., Floyd, R. L., Weber, M. K., O'Connor, M., Riley, E. P., Johnson, K. A., & Cohen, D. E. (2004). Fetal Alcohol Syndrome: Guidelines for referral and diagnosis. 62. Retrieved from http://www.cdc.gov/ncbddd/fasd/documents/fas_guidelines_accessible.pdf Competency-Based Curriculum Development Guide for Medical and Allied Health Education and Practice. (pp. 274). Washington, DC: U.S. Government Printing Office. Mattson, S. N., Crocker, N., & Nguyen, T. T. (2011). Fetal Alcohol Spectrum Disorders: Neuropsychological and Behavioural Features. [Review]. Neuropsychology Review, 21, 81-101. doi: 10.1007/s11065-011-9167-9 O'Connor, M. J., & Paley, B. (2009). Psychiatric conditions associated with prenatal alcohol exposure. Developmental Disabilities Research Review, 15(3), 10. Paley, B., & O’Connor, M. J. (2011). Behavioral interventions for children and adolescents with fetal alcohol spectrum disorders. Alcohol Research & Health, 34(1), 64-75. 29

30 Riley, E. P., Infante, M. A., & Warren, K. R. (2011). Fetal Alcohol Spectrum Disorders: An overview. [Overview]. Neuropsychology Review, 21, 73-80. doi: 10.1007/s11065-011-9166-x Stratton, K., Howe, C., & Battaglia, F. C. (1996). Fetal Alcohol Syndrome: Diagnosis, epidemiology, prevention, and treatment (pp. 230). Retrieved from http://www.nap.edu/catalog/4991.htmlhttp://www.nap.edu/catalog/4991.html Telethon Institute for Child Health Research. (). Alcohol Pregnancy & FASD. Retrieved from http://alcoholpregnancy.childhealthresearch.org.au/abou t/fetal-alcohol-spectrum-disorders- (fasd).aspx http://alcoholpregnancy.childhealthresearch.org.au/abou 30

31 Helpful Links http://dcanoy.wix.com/fas-disorders http://dcanoy.wix.com/fas-disorders Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code depts.washington.edu/fasdpn/pdfs/guide2004.pdf Brief outline of Diagnostic Criteria www.cdc.gov/ncbddd/fasd/documents/fas_guidelines_access ible.pdf​www.cdc.gov/ncbddd/fasd/documents/fas_guidelines_access ible.pdf​​ Australasian Paediatric Endocrine Group http://www.apeg.org.au/clinicalresourceslinks/growthgrowth charts/tabid/101/default.aspx 31

32 32 I invite you to complete and email the Feedback Form also located on this site to enhance further presentations. Thank You d.canoy@cqu.edu.au


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