Presentation on theme: "Preventing Alcohol Exposure and Fetal Alcohol Spectrum Disorders"— Presentation transcript:
1 Preventing Alcohol Exposure and Fetal Alcohol Spectrum Disorders Courtney Kihlberg, MD, MSPHAssistant ProfessorDivision of Preventive MedicineMeharry Medical CollegeNashville, Tennessee18 May 2012Funded by a grant from the Centers for Disease Control and Prevention (CDC) – 1U84DD000882
2 Preventing Alcohol Exposure and Fetal Alcohol Spectrum Disorders DISCLOSURESFunded by a grant from the Centers for Disease Control and Prevention (CDC) – 1U84DD000882No other support or disclosures
3 ObjectivesIncrease OB/GYN providers’ competency in preventing alcohol exposure during pregnancyReview the epidemiology, screening tools, and diagnostic criteria for fetal alcohol spectrum disordersExamine evidence-based practices in prevention, identification of, and multidisciplinary interventions for fetal alcohol spectrum disorders
5 “Practice Makes Perfect” Overcoming Barriers“Practice Makes Perfect”
6 How often do you and how recently have you… Queried one of your pregnant moms on alcohol intake in the household?Considered alcohol exposure in a women with a child from a prior pregnancy who has:Learning or behavioral difficulties (e.g. ADHD)?Organ or growth abnormalities?Dysmorphic features?
7 Barriers We Face as Providers Prevention of Alcohol Use among Pregnant WomenLack of trainingUncertain about how to intervene if problem is foundTime constraintsPersonal discomfortDiagnosis and Care of Children with FASDsFear of offending motherBelief that the harm is already doneWeisner C, Matzger H. Alcohol Clin Exp Res Jul;27(7): ; Nevin AC et al. BMC Fam Pract. 2002;3:2. Zoorob R, Aliyu MH, Hayes C. Alcohol Jun;44(4):
8 Breaking Down Barriers Neonatal diagnosis is NOT a hopeless prognosisAppropriate medical interventions + Community support =Minimized (though not eliminated) impact of alcohol-relatedbirth injury and neurodevelopmental disabilitiesPrevention in Future Pregnancies
10 Criteria for Diagnosing FAS With or WITHOUT confirmed fetal exposure to alcohol, diagnosis requires documentation ofAll three dysmorphic facial featuressmooth philtrum, thin vermillion border, small palpebral fissuresPre- or post-natal growth deficitStructural, neurologic, or functional central nervous system (CNS) abnormalityBertrand J, Floyd RL, Weber MK. Morbidity and Mortality Weekly Review. October 28, 2005/54;1-10
11 #1 Facial Abnormalities of FAS Smooth philtrumThin vermillion borderSmall palpebral fissuresPhoto courtesy of Teresa Kellerman
12 Lip-Philtrum GuideDeveloped by University of Washington FAS Diagnostic & Prevention NetworkGuide 1 – CaucasiansGuide 2 – African AmericansBack side provides face & height-weight tables from the FASD Diagnostic Guide (2004)Order frompn/htmls/order-forms.htm
13 Measuring the Palpebral Fissures Astley, et al. Magnetic Resonance Imaging Outcomes From a Comprehensive Magnetic Resonance Study of Children With Fetal Alcohol Spectrum Disorders. Alcoholism: Clinical and Experimental Research, Oct 2009.
14 Measuring the Palpebral Fissures accessed July 1, 2011.
15 Comparing Palpebral Fissure Measurements to Norms Active excel spreadsheet accessed from on July 1, 2011.
16 Accuracy of Methods for Measuring Palpebral Fissure Lengths Clear Plastic Ruler42% concordant with photometric measuresDiscordance: ruler equally smaller and largerBlunt Precision Slide Calipers18% concordant with photometric measures24% concordant with ruler measuresDiscordance: calipers usually measured largerSingle, experienced cliniciann = 50 children referred for FASD eval and 50 adult med studentsCranston, et al. Concordance of Three Methods for Palpebral Fissure Length Measurement in the Assessment of FASDs. Can J Clin Pharmacol, 2009.
18 Growth Deficiency (weight and/or height) 10% at any one point pre- or postnatal (adjusted for age, sex, gestational age, race/ethnicity)Photos courtesy of the University of Louisville Fetal Alcohol Spectrum Disorders (FASD) Clinic - Weisskopf Child Evaluation Center, and the FASD Southeast Regional Training Center at Meharry Medical College Department of Family and Community Medicine: FASDsoutheast.org Any use of these photos requires written permission from the University of Louisville FASD Clinic - Weisskopf Child Evaluation Center and the proper acknowledgement as written in this caption.
19 Astley, et al. Magnetic Resonance Imaging Outcomes From a Comprehensive Magnetic Resonance Study of Children With Fetal Alcohol Spectrum Disorders. Alcoholism: Clinical and Experimental Research, Oct 2009.
20 http://depts. washington. edu/fasdpn/htmls/face-software accessed July 1, 2011.
21 #2 Growth Deficits in FAS TimingPrenatal or PostnatalAt any one pointDegree≤ 10th percentile for age and sexadjusted for gestational ageHeight or Weight (or Head Circumference)
22 #3 CNS Abnormalities of FAS Structural AbnormalityHead Circumference ≤ 10th percentileClinically meaningful brain abnormalities observed through imaging (reduction in size or change in shape of corpus callosum, cerebellum, or basal ganglia)Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005/54;1-10.photo: Clarren, 1986.
23 Corpus Callosum Structural Abnormality A: 14 year old control subject: Normal corpus callosumB: 12 year old with FAS: Thin corpus callosumC: 14 year old with FAS: Agenesis of the corpus callosumMattson, S.N.; Jernigan, T.L.; and Riley, E.P MRI and prenatal alcohol exposure: Images provide insight into FAS. Alcohol Health & Research World 18(1): (used with permission)
24 #3 CNS Abnormalities of FAS Neurologic AbnormalityMotor problems or seizure NOT from a postnatal insult or feverOther soft neurologic signs outside normal limitsFunctional AbnormalityGlobal cognitive or intellectual deficits (IQ <3rd percentile)Substantial developmental delay in younger childrenFunctional deficits (<16th percentile) in at least 3 domains:Cognitive or developmental deficits Executive functioningAbstract concepts Problem solvingMotor functioning Attention problems/hyperactivitySocial skills Other (sensory, memory, language)Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005/54;1-10
25 What are FASDs?“Fetal Alcohol Spectrum Disorder” is NOT a diagnostic category, but rather an umbrella term describing a range of effects that can occur in a person whose mother drank alcohol during pregnancyBertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005 / 54;1-10.
26 FASD 4-Digit Diagnostic Code Ranks each of the following on a 4 point scale:GrowthFaceCNSAlcohol Exposure256 possible 4-Digit Code combinationsAll combinations assigned to one of 22 Diagnostic CategoriesAstley, SJ. Diagnostic Guide for FASD: The 4-Digit Code, 3rd Edition, Accessed from on July 5, 2011.
27 Astley, SJ. Diagnostic Guide for FASD: The 4-Digit Code, 3rd Edition, Accessed from on July 5, 2011.
28 Astley, SJ. Diagnostic Guide for FASD: The 4-Digit Code, 3rd Edition, Accessed from on July 5, 2011.
29 From FAS Diagnostic Criteria to Life with an FASD…. IQ averages 60, rangePoor JudgmentProblems withBehaviorMotor SkillsSocial InteractionsExcessive body contactImpulsivenessIntrusivenessLack of stranger anxiety
30 …. Even Beyond Early Childhood Disrupted Schooling43% of teens with FASDs are at high risk of having school interrupted by suspension, expulsion, or from dropping outConduct ProblemsAntisocial BehaviorsInability to follow rules, lying, and stealingDifficulties SocializingMaintaining FriendshipsDepression and AnxietyInappropriate SexualityGOALIndependent Living
32 0.2 to 1.5 per 1,000 Epidemiology of FASDs caveats Actually Diagnosed FAS vs. FASDRegional Variances
33 Incidence of FASDsComparable with or higher than rates for other common developmental disabilities (Down syndrome, spina bifida)0.2 to 1.5 cases of FAS per 1,000 live births in the USRates in other studies range from 0.5 to 2.0 cases per 1,000Other FASDs are believed to occur about 3 times as often as FASCDC. MMWR Morb Mortal Wkly Rep 2002;51:CDC. A Call to Action: Advancing Essential Services and Research on Fetal AlcoholSpectrum Disorders. March Accessed from
34 Prevalence in Other Countries South AfricaHighest reported prevalence rates of FAS in the worldIn 2000: per 1,000 childrenIn 2002: per 1,000 childrenIn 2011: 70 – 80 per 1,000 children(partially attributed to increase in provider awareness and recognition of diagnosis)Russia20% of children in Moscow orphanages and boarding schools had physical features of FAS (N=1,000)May et al., Am. J. of Public Health 90 (2000); Viljoen et al., J. Stud. Alcohol 66 (2005). Riley et al, Alcohol Clin Exp Res (2003).Bulletin of the World Health Organization 2011;89:398–399. doi: /BLT
35 Reported incidence rate of FAS, by year of birth, CDC Birth Defects Monitoring Program, 1979-1992 Courtesy: NIAAA webpage. Cordero, J.F., et al. Alcohol Health & Research World 18(1):82–85, 1994.
36 Prevalence of Alcohol Use Among Women of Childbearing Age Known vs. Unknown PregnanciesFrequency of UseOccasional / Any UseBinge4 or more drinks on one or more occasions for women5 or more drinks on one or more occasion for menKanny, Liu, Brewer. “Binge drinking – United States 2009.” CDC, MMWR.Photo: courtesy of Dang, CDC.
37 Any use in pregnancy - 12.2% or 1 in 8 Binge in pregnancy – 1.9% or 1 in 50
38 Accessed from www.cdc.gov/ncbddd/fasd/data.html on May 14, 2012.
39 State-specific weighted prevalence estimates of Alcohol use among Women Aged 18–44 Years, BRFSS, 2010StateAny Use*Binge†Florida49.713.5Utah21.57.0Wisconsin67.722.7US (median)51.215.2* 1 or more drinks during the last 30 days† 4 or more drinks on any one occasion during the last 30 daysstandard drink: 0.60 ounces of pure alcoholequivalent to one 12-ounce beer or wine cooler, one 5-ounce glass of wine,or 1.5 ounces of 80 proof distilled spirits [hard liquor]
40 Females Aged Years Reporting Past Month Binge† Alcohol Use, by Race/Ethnicity and Pregnancy Status, 2002 and 2003 Combined† Binge = 5 or more drinks on the same occasion on at least 1 day in the past 30 daysSubstance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health 2005
41 Percentage of Female (>18 years of age) Current Drinkers by Race/Ethnicity White63Hispanic or Latino39.7African American38.5Alcohol consumption among adults 18 years of age and over, by selected characteristics: United States, 1997, 2004, From National Center for Health Statistics. Health, United States, Table 68 (1 of 3). Hyattsville, MD: 2007.
42 Percentage of Female (>18 years of age) Binge † Drinkers by Race/Ethnicity White22.6Hispanic or Latino16.9African American13† Binge = 5 or more drinks on the same occasion on at least 1 day in the past yearAlcohol consumption among adults 18 years of age and over, by selected characteristics: United States, 1997, 2004, From National Center for Health Statistics. Health, United States, Table 68. Hyattsville, MD: 2007.
43 Biologic Plausibility and Mechanism of Action BrainNervesBrainStomachPlacentaFetusBreastHeartOrgansLiverMusclesKidneys
45 Areas of the brain that can be damaged in utero by maternal alcohol consumption Warren & Foudin. Alcohol Research & Health 25(3):153–158, 2001.
46 Major Effects of Alcohol by Trimester Courtesy UCLA RTC.
47 Baldwin. Fetal Alcohol Spectrum Disorder, Florida Resource Guide Baldwin. Fetal Alcohol Spectrum Disorder, Florida Resource Guide. Accessed from on April 30, 2012.
48 Time to TWEAK your neighbor Any Volunteers?How to screen for andprevent alcohol use in pregnancy
49 TWEAK Alcohol Assessment Originally developed to screen for at-risk drinking during pregnancyProven effectiveness in pregnant women and African- American women of low SESFive-item scale
50 "Do you sometimes take a drink in the morning when you first get up?" T - Tolerance"How many drinks does it take you to feel the first effects of the alcohol?"W - Worry"Have close friends or relatives worried or complained about your drinking in the past year?"E - Eye-Opener"Do you sometimes take a drink in the morning when you first get up?"A - Amnesia"Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?" (blackouts)K(C) - Cut Down"Do you sometimes feel the need to cut down on your drinking?"
51 TWEAK Scoring Tolerance: 3 or more drinks to feel effect = 2 points Worry: Yes = 2 pointsEye Opener: Yes = 1 pointAmnesia: Yes = 1 pointCut Down: Yes = 1 pointPregnant WomenScore of >0 indicates at-risk drinkingNon-PregnantScore of 2 indicates likelihood of at-risk drinkingScore of ≥ 3 indicates problem drinking or alcoholismChang G. Alcohol Research and Health. 2001;25(3):
52 Audio Computerized Self-Report Interview Ear phones used with recorded voice asking questionsTWEAK plus questions on quantity and frequency during 3 months prior to pregnancy through presentValidated in low SES, low literacy minority populationThornberry, et al. Nursing ; 20(2):46-52.
53 Baldwin. Fetal Alcohol Spectrum Disorder, Florida Resource Guide Baldwin. Fetal Alcohol Spectrum Disorder, Florida Resource Guide. Accessed from on April 30, 2012.
54 Ask, Assess, Advise, Assist Method Do you drink alcohol, including beer, wine or hard liquor?On average, how many days per week do you drink alcohol?On a typical day when you drink, how many drinks do you have?What’s the maximum number of drinks you had on a given occasion in the last month?
56 Advise and AssistBrief Interventions have been found to be effective with female problem drinkers in primary-care clinics5-10 minute counseling session can reduce alcohol use in women by 20-30%Wallace P, et al. BMJ1988;297(6649): Fleming MF, et al. JAMA ;277(13):
57 Brief Intervention: Ask and Assess Risk Level Raise the subject: Alcohol Assessment Test“I like to ask all my patients about their drinking patterns”Does the patient have alcohol-related problems? (Medical, behavioral, social, familial)Provide feedback about alcohol risk level: Relate health concerns / pregnancy risks to alcohol use“I am very concerned about how your drinking may affect your health”“There is no known safe limit for drinking during pregnancy. You need to stop drinking completely b/c when you drink, your baby drinks.”
58 Brief Intervention: Advise and Assist Engage the patient in the process: Assess, enhance motivation and patient responsibility“How do you feel about your drinking?”For alcohol-risk, establish drinking goals: Advise and negotiate cut down“Are you ready to set a drinking goal? What do you think will work best for you?” (give brochure materials)For alcohol dependence, advise abstinence and refer to specialized treatment.Follow up: review progress, commend effort, reinforce positive change, reassess motivationNIAAA, Office of Research on Minority Health, Identification of At Risk Drinking and Intervention with Women of Childbearing Age. NIH Publication No (1999)
60 Decrease unintended pregnancies Start with the Basics!Decrease unintended pregnanciesInitiate contraceptive effortsConfirm proper andconsistent useExample from Project CHOICESChanging High-Risk AlcOhol Use &Increasing Contraception Effectiveness StudyPhoto: courtesy Dang, CDC.
61 Project CHOICES 4 motivational counseling sessions and a contraception consultation visitdelivered over weeksAt 3, 6, and 9 month follow-up, the odds for reducing the risk of an Alcohol Exposed Pregnancy (AEP) were 2-fold higher among women receiving the intervention as compared to the control group.Recruit non-treatment-seeking women at risk for AEP:Fertile and years of ageSexual intercourse w/ a man in past 3 monthsUsing ineffective or no contraceptionDrinking 8 or more drinks per week ORDrinking 5 or more drinks on one or more days in last 3 months.“Reduced” AEP risk: using effective contraception OR drinking below risky levels71% still in study at 9-month follow-upBoth groups had reduced riskMore intervention women changed both behaviorsNot at risk by: intervention controlAlcohol % 40%BC % 39%Floyd, et al. Preventing Alcohol-Exposed Pregnancies: A Randomized Controlled Trial American Journal of Preventive Medicine; January 2007; 32(1):1-10.
62 It may be difficult to talk with patients about alcohol use and the prevention of FASDs, but you can do it and there are resources that can help!
63 Improving Healthcare Provider Practices MonitoringHealth Education & PromotionPartners & PolicyCDC’s FAS Prevention TeamDissemination of Effective InterventionsIntervention ResearchElizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention
64 FASD Regional Training Centers (RTCs) In 2002, Congressional language indicated that the CDC would…Develop guidelines for the diagnosis of FAS and other prenatal alcohol-related conditionsIncorporate these guidelines into curricula for medical and allied health students and practitionersCDC funded the original four RTCsSoutheast: Meharry Medical CollegeNortheast: Univ of Med & Dentistry of New JerseyMidwest: Saint Louis UniversityWest: UCLAElizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention
65 Current RTCs 2011-2014 Southeast: Meharry Medical College Great Lakes: Univ of WisconsinArctic:Univ of Alaska,AnchorageFrontier:Univ of Nevada, RenoMidwest:Saint Louis Univaccessed April 30, 2012.
66 Tools from www.cdc.gov/fasd Adapted from Elizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention
67 FASD Prevention Tool Kits Developed by ACOG and CDCBrief guideLaminated screeninginstrumentResource informationPatient handoutsPocket CardiPhone App
68 Accessed from http://www. womenandalcohol. org/clinicians Accessed from on April 30, 2012.
69 Targeting Specific Groups Prevention MaterialsTargeting Specific GroupsLos Angeles County, CaliforniaSt. Louis, MOIowa
70 “Keep It Simple” FASDs are 100% preventable there is no known safe amount of alcohol to drink while pregnant there is no safe time during pregnancy to drinkthere is no safe type of alcohol“Practice Makes Perfect”for providers regarding screening and prevention
71 FASD Interventions and Treatments For those living with an FASD
72 Multidisciplinary Approach is Critical Medical TreatmentMental Health TreatmentPharmacotherapyBehavioral Therapies and InterventionsSkilled Nursing ServicesPhysical, Occupational, and Speech TherapyEducational InterventionsEarly Intervention ServicesExceptional EdTeacher In-Service TrainingPositive Behavior Support Programming: focuses on specific behaviors, the environmental factors that contribute and understanding the intent of the behaviors.Cognitive-Behavioral Strategies: social skills training, emotion identification, coping skills, anger management and self-talkExecutive Function Training: behavioral awareness and self-controlEDUCATION:Using concrete, hands-on learning methodsEstablishing structured routinesKeep instructions short and simpleConsistent and specific directionsRepeating tasks over and overConstant supervisionDifferent approaches needed compared to children with other disorders (i.e. ADHD), esp with Math (Jacobson, et al. Processing, 2011.)Green JH. Fetal Alcohol Spectrum Disorders: Understanding the Effects off Prenatal Alcohol Exposure and Supporting Students. Journal of School Health. March 2007;77:
73 Resources for Educators Development ofIndividual Education Plans (IEPs)SAMHSA, 2007.Teaching Students with Fetal Alcohol Syndrome/Effects. British Columbia, Accessed from on June 15, 2011.
74 Multidisciplinary Approach is Critical Caregiver SupportSpecial consideration for Birth MothersParent Training
75 Multidisciplinary Approach is Critical Case ManagementArt and MusicTherapyService Animals…. and more….
76 Intervening with Children with FASDs Marcus InstituteLearning readinessMathU. OklahomaHealth SciencesPreschooler BehaviorU. WashingtonClinically Sig. Behavior ProblemsU. CaliforniaLos AngelesFriendshipsSocial skillsChildren’sResearch TriangleExecutive FunctioningCDCUCLA – 12 week, playdates, homework, take home techniquesMarcus – math tutoring, parent supportU Oklahoma – 14 sessions with therapist coaching -> decreased parent stressTriangle – behavior regulation, conductWashington – self-care, family needsElizabeth P. Dang, MPH, Behavioral Scientist, FAS Prevention Team, National Center on Birth Defects and Developmental Disabilities, CDC.
77 Information and Treatment Resources National Organization on FAS (NOFAS)(202)Local Alcohol and Drug Treatment ResourcesCDC FASD Home PageSoutheast Fetal Alcohol Spectrum Disorder Regional Training Center(FASD RTC) in the Meharry Medical College Department of Family & Community Medicine615)
78 Pensacola Resources Florida Department of Health Healthy Start ofas_friends.htmlLink to the 2005 guide from FSU Center for Prevention and Early Intervention PolicyHealthy Startbeing redesigned from April 2011 – March 2013Florida Alcohol and Drug Abuse Association
79 Preventing Alcohol Exposure and Fetal Alcohol Spectrum Disorders QUESTIONSFunded by a grant from the Centers for Disease Control and Prevention (CDC) – 1U84DD000882