1. Fetal Alcohol Syndrome

2. Two Hundred and Fifty-Eight Cases of Suffocation of Infants By Charles Templeman, M.D., B.Sc. (Pub. Health), Surgeon of Police; Surgeon to the Royal Infirmary, Dundee. (Read before the Medico-Chirurgical Society of Edinburgh, 1 st June 1892.)

3. If drinking over 2 years prior to pregnancy, mortality rate 62.7%  46% deaths occur on Saturday night and Sunday morning

4. A Note on the Influence of Maternal Inebriety on the Offspring By W. C. Sullivan, M.D., and Stewart Scholar in Mental Disease, R.U.I., Deputy Medical Officer, H.M. Convict Prison, Parkhurst (July, 1899)

5. Mortality  Women n = 100 (plus 20 female relatives) 600 Children  335 (55.8%) died  80 women had 3 or more dead infants

6. Second Cause of Death: Maternal Drunkenness

8. Alcohol Related Birth Defects and Developmental Disabilities Fetal Alcohol Syndrome © Larry Burd, Fetal Alcohol Syndrome Center, University of North Dakota

9. Due to Prenatal Exposure P FAS P FAE P ARND P ARBD

10. Assessment of Exposure During Pregnancy On average how many days per week did you drink during pregnancy? _____(a) What is the most you had to drink on any one day during pregnancy? _____ On an average drinking day during pregnancy how many drinks did you have? _____(b) Exposure Parameters (Cumulative exposure during pregnancy)  Pregnancy Drinking Days = ( a x 40 ) = _____(c)  Estimate of number of drinking days during pregnancy.  Percent of Days Exposed During Pregnancy = ( c ÷ 280 ) =  Estimate of days exposed during pregnancy. _____  Number of Drinks During Pregnancy = ( a x b x 40 ) =  Estimate of number of drinks during pregnancy. _____(d)  Ounces of absolute alcohol = ( d ÷ 2 ) = _______  Estimate of exposure to absolute alcohol during pregnancy.

12. Comparison of North Dakota Children with Fetal Alcohol Syndrome (FAS) to children with Fetal Alcohol Effect (FAE). VariableNMeanSD ___________________________________________________________ __ Birth Weight (grams) FAS442766.6512.1 * FAE243087.7676.8 ___________________________________________________________ ___ Mother's Age (years) FAS 4427.35.4 FAE 2427.34.8 ___________________________________________________________ ____ Father's Age (years) FAS2332.310.2 FAE1730.66.5 ___________________________________________________________ ____ Weight Gain (kilograms) FAS77.36.8 FAE411.64.5 ___________________________________________________________ ____ Gestation (weeks) FAS838.61.8 FAE537.81.1 ______________________________________________________________ Apgar (1 Minute) FAS357.31.6 FAE187.71.0 ___________________________________________________________ ____ Apgar (5 Minute) FAS358.71.0 FAE188.80.9 ___________________________________________________________ ____ * Significant at.05

13. Comparison of North Dakota Children with FAS or FAE to the control group. Four controls were selected for each case. _________________________________________________________ _____ VariableNMeanSD __________________________________________________________ ___ Birth Weight (grams) ** FAS/FAE682880.0591.2 Control2723467.1656.1 __________________________________________________________ ____ Mother's Age (years) ** FAS/FAE6827.35.2 Control27224.85.3 __________________________________________________________ ____ Father's Age (years) ** FAS/FAE4031.68.8 Control21127.66.4 __________________________________________________________ ____ Weight Gain (kilograms) ** FAS/FAE118.86.3 Control5213.95.6 __________________________________________________________ ____ Gestation (weeks) FAS/FAE1338.31.5 Control5239.11.9 __________________________________________________________ ____ Apgar (1 Minute) FAS/FAE537.51.4 Control2177.41.7 __________________________________________________________ ____ Apgar (5 Minute) FAS/FAE538.70.9 Control2178.91.0 __________________________________________________________ ____ ** Significant at.01

14. Comparison of Categorical Variables for Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effect (FAE) Groups Combined to the Control Group (four controls per case). __________________________________________________________________________________________ 95% Confidence Group FAS/FAE Controls ORIntervals Variablesn (%) n (%) (Yates’)p-value __________________________________________________________________________________________ Marital Status Not Married38(58)113(43)1.83(1.02, 3.30) Married27(42)147(57)4.12.042* Smoking During Pregnancy Yes8(62)19(37)2.78(0.79, 9.71) No5(38)33(63)1.75.186 Alcohol Use During Pregnancy Yes9(69)4(8)27.00(5.68, 128.24) No4(31)48(92)20.92#.000** Number of Prenatal Visits 0-537(56)73(27)3.44(1.91, 6.23) >529(44)197(73)18.99.000** Live Births Now Dead 1 or More12(18)16(6)3.40(1.42, 8.12) None56(82)254(94)8.34.004** Trimester Prenatal Care Began 2nd or 3rd20(35)112(42)0.73(0.39, 1.38) 1st37(65)152(58)0.76.383 __________________________________________________________________________________________ # = Fisher exact used for p-value * = Significant at.05 level ** = Significant at.01 level

15. Comparison of Categorical Variables for Native American (NA) Children to White Children With the Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects Groups (FAE) Combined ______________________________________________________________________ _ FAS/FAE Combined VariablesN MeanSD _______________________________________________________________________ Birth Weight (grams) White182925.8609.8 NA502863.5589.7 _______________________________________________________________________ _ Mother's Age (years) White 1825.14.7 NA5028.15.1 _______________________________________________________________________ __ Father's Age (years) White1131.67.2 NA2931.69.5 _______________________________________________________________________ __ Weight Gain (kilograms) White212.54.8 NA98.16.4 _______________________________________________________________________ __ Gestation (weeks) White339.01.0 NA1038.11.7 ________________________________________________________________________ Apgar (1 Minute) White157.71.0 NA387.31.5 _______________________________________________________________________ __ Apgar (5 Minute) White158.41.1 NA388.90.9 _______________________________________________________________________ __

16. Maternal and Paternal Risk Factor for FAS from 132 Cases of FAS/FAE from North Dakota (adapted from Bagheri and Burd)21 _______________________________________________________________________________ VariableCase/ControlMean (Difference)p-value Case/Control _______________________________________________________________________________ Mother's Age (years)132/66027.4/25.4 (2.0)<0.001 Father's Age (years)43/21532.0/27.8 (4.2)<0.001 Weight gain in pregnancy (lbs.)33/16522.1/30.4 (8.3)<0.001 Gestation (weeks)101/50538.7/40.0 (1.3)<0.001 Month prenatal care began123/6153.4/2.7 (0.7)<0.001 Number prenatal visits123/6155.5/9.7 (4.2)<0.001 Mother's education125/62510.6/13.0 (2.4)<0.001 Father's education32/16010.8/13.2 (2.6)<0.001 _______________________________________________________________________________

17. Increased Probability of a Previous Child with Fetal Alcohol Syndrome Total number of live births prior to birth of FAS child Number of children with FAS in prior births Estimated incidence of FAS per 1,000 live births Incidence of FAS in previous births per 1,000 live births Risk increased by 13523.97170.4172x Source: E.L> Abel, Fetal Alcohol Syndrome in Families, Neurotoxicity and Teratology (1988), 10, pp.1-2. Copyright 1988 by Elsevier Science, Adapted with permission of the publisher.

18. Increased Risk of Having a Second Child with Fetal Alcohol Syndrome Total number of live births after birth of FAS child Number of children with FAS in subsequent births Estimated incidence of FAS per 1,000 live births Incidence of FAS in subsequent births per 1,000 live births Risk increased by 3527.97771795x Source: E.L> Abel, Fetal Alcohol Syndrome in Families, Neurotoxicity and Teratology (1988), 10, pp.1-2. Copyright 1988 by Elsevier Science, Adapted with permission of the publisher.

20. MATERNAL RISK SCORE SCORE ____ Age Over 25 years ____Unmarried, Divorced, Widow, Living with PartnerCheck any one, ____On AFDC, WIC, Social Security or Income < $16,000 Per Year Add 5 ____Did not Graduate From High School ____Poor Diet ____Smokes More Than ½ Pack per Day ____Drinks less than 2 days/week & less thanCheck here, 2 drinks /drinking day Add 20 ____Age First Drunk Less Than 15 years ____In Treatment Over Three Times ____In Treatment in Last 12 MonthsCheck any one, ____Previous Child With FAS, FAE, Birth Defect, Add 35 or Developmental Disability ____Previous Child Died ____Children Out of Home (Foster Care or Adopted) Check any one, ____Heavy Drinker (3 or more days per week or over 3 drinks Add 45 per drinking day) ____Uses Inhalants, Sniffs or Illegal Drugs Score Risk Category Recommendations 0 None Standard Prenatal Care 5 Low Standard Prenatal Care 20-40 Moderate Standard Prenatal Care and Patient Education on FAS 45-50 High High Risk pregnancy, Alcohol-Drug Abuse Treatment 55-85 Very HighHigh Risk Pregnancy, Inpatient Treatment Total Score Prenatal Copyright 2000

21. THE MOMS Age27.4 Education10.6 Unmarried63% Smoker82% Alcoholic10+ years Heavy Drinker> 10 day + Treatment> 3 45% Minority73% Poor+ Poor Diet+ Parity3 Prenatal (1 st )1 Prenatal visits<3 Maternal Deaths FAE4.1% FAS4.5% Number of prenatal complications Number of prenatal visits Monthly prenatal care starts Birth weight Number of malformations

22. THE DADS Age30.8 Education10.9 Unmarried63% Alcoholic12 + years Heavy Drinker+ Treatment> 3 Minority60% Poor+ Other terminations Number of prenatal visits Number of prenatal complications

23. THE CHILDREN Age Diagnosis7.1 years Older Sibs2 Younger2 Birth Defects50% Cerebral Palsy6% Mental Retardation40% ADHD60% Out of Home85% Head Injury25% Dead Sibling FAE 1 = 2%FAS1 = 1% 2 = 0 2 = 2% 3 = 0 3 = 5%

24. THE DADS Age30.8 Education10.9 Unmarried63% Alcoholic 12+ years Heavy Drinker + Poor + THE MOMS Age27.4 Education10.6 Unmarried63% Smoker82% Alcoholic 10+ years Heavy Drinker> 10 day Treatment >3 times (45%) Poor + Poor Diet + Parity 3 Prenatal (1 st ) 1 Prenatal visits< 3 Maternal deaths FAE4.1% FAS4.5% THE CHILDREN Age diagnosis7.1 years Older sibs2 Younger2 Birth defects50% Cerebral Palsy6% Mental retardation40% ADHD60% Out of Home85% Head Injury25% Dead Sibling FAS/FAE11.4% Controls2.0%

25. Ten-Year Follow-Up of FAS Children 18% Had Died 27% of the Mothers Had Died (Streissguth, 1985)

28. Examination of the developing mouse brain following alcohol exposure shows cells that have been killed. Apoptotic cells Nile blue stained in two of the pictures and dark brown at bottom right. Kindly provided by Dr. K Sulik and Dr. W Dunty, Univ of North Carolina

29. Ikonomidou C, et al. Science 287:1056-1060, 2000.

30. Impairments in: Memory Attention Adaptive behavior Use of social rules Sleep Behavior regulation

33. __________________________________________________________________________________________ Secondary Disabilities in 400 Adolescents and Adults with Fetal Alcohol Syndrome and Fetal Alcohol Effect __________________________________________________________________________________________ 1.Mental Health problems: 90% 2.Disrupted School Experience (suspended or expelled from school of dropping out of school): 60% 3.Trouble With the Law: 60% 4.Confinement: Includes inpatient treatment for mental health problems, alcohol/drug problems, or incarcerated for a crime. 50% 5.Inappropriate Sexual Behavior: 50% 6.Alcohol/Drug Problems: 30% Protective Factors 1.Living in a stable and nurturing home for over 72% of life. 2.Being diagnosed before the age of 6 years. 3.Never having experienced violence against oneself. 4.Staying in each living situation for an average of more than 2.8 years. 5.Experiencing a good quality home from age 8 to 12 years. 6.Having applied for an been found eligible for Division of Developmental Disabilities services. 7.Having a diagnosis of FAS. 8.Having basic needs met for at least 13% of life. __________________________________________________________________________________________

34. FAS in North Dakota  Annual Births 10-18  0-18 180-324  Adult 360-800

35. North Dakota Alcohol Income (2000) Wholesale tax$ 5,500,000 Sales tax$14,500,000 Total$20,000,000

36. 3.9 Million Births 1,560,000 Exposed 137,000 Frequent heavy drinking 39,000 FAS-RD The National Center on Addiction and Substance Abuse, 1999

37. Tom Welty MD AAIHS 1998 Prevalence Rate FAS AAIHS: 8 per 1,000 live births. 2 to 8 times above other population estimates.

38. Tom Welty MD AAIHS 1998 Estimated Lifetime Cost per person to care for their needs: $1-$4 million Total Lifetime estimated cost for FAS cases that occurred in Aberdeen Area in 1990: $21-$84 million Total costs for all alcohol-related developmental disabilities are much higher since projections are based only on confirmed FAS cases.

39.  Lost productivity due to FAS: Adults - $1,000,000,000/annually $2,739,000/day  Health care costs due to FAS: Children and adults - $2,000,000,000/annually $5,479,000/day The National Center on Addiction and Substance Abuse, 1999

41. Treatment of FAS Start early-Avoid Abuse Avoid multiple foster homes Treat in community Make a place in the community Avoid problem peers Use legal system Long term treatment-more than 10 years

42. A Developmental Management Model for Children and Adults With FAS and Related Disorders _____________________________________________________________________________ Newborn Management: 1.Diagnostic assessment of both physical and neurologic anomalies 2.Early involvement of child protective services. 3.Referral to the Department of Human Services for initiation of infant stimulation. 4.Prevention of secondary disabilities, specific to age group; abuse, vision/hearing deficits. 5.Referral of mother to substance abuse treatment program. 6.Sensory evaluation (vision and hearing). Childhood Management: 1.Head Start Program with special learning environment, addressing specific learning disabilities. 2.Annual developmental assessment. 3.Referral for services to address neurologic deficits and psychosocial delays. 4.Prevention of secondary disabilities.

43. Monitoring social skill development Adolescent Management: 1.Prevention of secondary disabilities, specifically drug and alcohol use. Prevention of school failure, social problems and institutionalization. 2.Vocational training, preparation for future employment. 3.Continuation of developmental assessments. 4.Develop long term plan (10 years). 5.Social skill development and monitor peer group. Adult Management: 1.Employment services (vocational rehabilitation). 2.Social services and long-term support. 3.Monitor for substance abuse. 4.Enhance awareness in adult service systems: mental health, substance abuse, corrections. ________________________________________________________________________

45. SCREENING FOR ALCOHOL ABUSE TWEAK Test (Russell 1984) TOLERANCEHow many drinks can you hold? If more than 5 drinks = 2 points WORRYHave close friends or relatives worried or complained about Your drinking in the past year? Yes = 2 points EYE-OPENERDo you sometimes take a drink in the morning when you first get up? Yes = 1 point AMNESIAHas a friend or family member ever told you about things you said or did while you were drinking that you could not remember? Yes = 1 point K/CUT DOWNDo you sometimes feel the need to cut down on your drinking? Yes = 1 point A score of 2 or above places the woman in a risk category and requires further assessment.

46. DIAGNOSTIC CRITERIA FAS AND ALCOHOL RELATED EFFECTS (3, 4, and 5 require the presumption that the finding is due to prenatal alcohol exposure) 1.FAS confirmed alcohol exposure A.confirmed maternal alcohol exposure B.characteristic facial anomalies C.growth retardation D.neurodevelopmental abnormalities 2.FAS without confirmed maternal alcohol exposure B, C, and D above 3.Partial FAS with confirmed maternal alcohol exposure A.confirmed maternal alcohol exposure B.some or partial characteristic facial features C.growth retardation D.neurodevelopmental abnormalities E.behavioral or cognitive abnormalities presumed due to prenatal alcohol exposure 4.Alcohol-Related Birth Defects (ARBD) Cardiac Ocular-Auditory Other Skeletal Renal 5.Alcohol-Related Neurodevelopmental Disorder (ARND) A.CNS neurodevelopmental abnormalities B.Complex pattern of behavior or cognitive abnormalities

48. Prevention of FAS 10-18 cases of FAS born each year in ND. Treatment 50% Effective Alcohol Use & Other Risk Factors Risk of FAS Women Treated Women Quit * Cases Prevented Cost per Case Prevented Daily Alcohol Use 0.01%20,00010,0001$100,000,000 Heavy drinkers, middle class, non-smokers.29%69034413,450,000 Heavy drinkers, low in- come, smokers, poor diet 4.3%47231235,000 Women who have had a previous child with FAS 75%31115,000 * Quit after one year.

49. Prevention Plan High Risk Communities Service Systems Risk Factor Prevalence Case Demographic Data Birth Certificates Community Assessment Community Assessment Community Assessment Social Services Criminal Justice Treatment Programs Birth Certificate Data Risk Factor Prevalence Services Community Characteristics Prevention Plan Birth Certificates Risk Factor Prevalence Parental Demographics Mortality Previous Deaths Service Systems High Risk Community Prevention Plan FAS/FAEREGISTRY Program Reviews Age-Cause Maternal-Paternal Characteristics 1.Education 2.Marital Status 3.Race 4.Prenatal Care 5.Age 1. First visit 2. Total visits 3. Number of visits in first trimester 4. Previous child deaths 5. Other risk factors Program Assessments EPSDT WIC Social Services Criminal Justice Special Education Cases Parents Community

50. 40% of those who start drinking at 14 years or younger develop alcohol dependence compared with 10% of those who begin drinking at 20 years or older Rivara FP, Whitaker R, Sherman PM, Cuttler L, Influencing the Childhood Behaviors That Lead to Obesity: Role of the Pediatrician and Health Care Professional. 2003. Arch Pediatr Adolesc Med.