Practice amp Implementation Center South at Baylor College of Medicine Learning Objectives Describe the effects of alcohol exposure during pregnancy Identify the signs and symptoms of fetal alcohol spectrum disorders ID: 777318
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Slide1
Overview of Fetal Alcohol Spectrum Disorders & Alcohol Exposed Pregnancy
Practice & Implementation Center – South at Baylor College of Medicine
Slide2Learning Objectives
Describe the effects of alcohol exposure during pregnancy
Identify the signs and symptoms of
fetal alcohol spectrum disorders
(FASDs)
Discuss the stigma and ethical dilemmas associated with
alcohol exposed pregnancy
(AEP) and FASDs
Slide3Alcohol Use and Health
3 out of 10 Americans drink at levels that elevate health risks
(NIAAA, 2016)
29K alcohol induced deaths annually in the US
(CDC, 2013),
excluding homicides and accidentsFAS/FASDs are the number one preventable cause of birth defects and intellectual disabilities (NIAAA, 2016)45% of all pregnancies are unplanned (Finer and Zolna, 2016)Women who drink alcohol may not realize they are pregnant until significant exposure has occurred (SAMHSA NSDUH, 2014)
Women
ages
15-44
Pregnant Women
Current
drinkers
54%
11%
Binge drinkers
24%
5%
Heavy drinkers
6%
1%
Slide4A Mother’s Story
Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration. Recovering Hope: Mothers speak out about
Fetal Alcohol Spectrum Disorders. At
http://www.ncadi.samhsa.gov
.
Slide5When was the last time you…
Considered in-utero alcohol exposure in a patient:
With learning or behavioral difficulties (e.g., ADHD)?
In legal trouble or with a history of incarceration?
Who has difficulty holding a job or living independently as an adult?
Who is friendly and social during visits and yet seems unable to consistently follow agreed upon, simple treatment plans?
Slide6Criteria for Diagnosing FAS
With or WITHOUT confirmed fetal exposure to alcohol, diagnosis requires documentation of:
1)
All THREE
dysmorphic facial features:
smooth philtrum, thin vermillion bordersmall palpebral fissures2) Pre- or post-natal growth deficit 3) At least ONE central nervous system (CNS) abnormality:functionalneurologicalstructuralBertrand J, Floyd RL, Weber MK. Morbidity and Mortality Weekly Review. October 28, 2005/54;1-10
Slide7#1 Facial Abnormalities of FAS
Smooth philtrum
Thin vermillion border
Small palpebral fissures
Photo courtesy of Teresa Kellerman
Slide8Lip-Philtrum Guide
Developed by University of Washington FAS Diagnostic & Prevention Network
Guide 1 – Caucasians
Guide 2 – African Americans
Back side provides face & height-weight tables from the FASD Diagnostic Guide (2004)
Order from http://depts.washington.edu/fasdpn/htmls/order-forms.htmhttp://fasdcenter.samhsa.gov/educationTraining/courses/CapCurriculum/competency2/facial2.cfm
Slide9Measuring 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.
Slide10Astley, 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.
Slide11#2 Growth Deficits in FAS
Timing
Prenatal or Postnatal
At any ONE point
Degree
≤ 10th percentile adjusted for age, sex, race or ethnicity, and for gestational ageHeight or Weight (or Head Circumference)
Slide12#3 CNS Abnormalities of FAS
Structural Abnormality
Head Circumference
≤ 10
th
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.
Slide13Corpus Callosum Structural Abnormality
A: 14 year old control subject: Normal corpus callosum
B: 12 year old with FAS: Thin corpus callosum
C: 14 year old with FAS: Agenesis of the corpus callosum
Mattson, S.N.; Jernigan, T.L.; and Riley, E.P. 1994. MRI and prenatal alcohol exposure: Images provide insight into FAS.
Alcohol Health & Research World 18(1): 49-52
. (used with permission)
Slide14#3 CNS Abnormalities of FAS
Neurologic Abnormality
Motor problems or seizure NOT from a postnatal insult or fever
Other neurologic signs outside normal limits
Functional Abnormality
Global cognitive or intellectual deficits Substantial developmental delay in younger children Functional deficits in at least 3 domains:Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005/54;1-10Cognitive/developmental deficitsExecutive functioningMotor functioningAttention problems/hyperactivitySocial skillsOther -sensory, memory, language
Slide15What are FASDs?
“Fetal Alcohol Spectrum Disorders” is NOT a diagnostic category, but rather an umbrella term describing a range of effects that can occur in a person who was
exposed to alcohol
prenatally.
Bertrand J, Floyd RL, Weber MK. MMWR. October 28, 2005 / 54;1-10.
Slide166-9 weeks = FAS facial features
Organ damage in first 12 weeks
Brain effects throughout
Slide17Major Effects of Alcohol by Trimester
Courtesy UCLA RTC.
Slide18Learning Disorders
Verbal Learning:
FASDs affect people’s ability to initially encode in memory, but once encoded, recall is not affected
By comparison, in Down syndrome, both encoding and recall are impaired.
Visual-Spatial Learning: difficulty with learning spatial relationships between objects and with mathematics.
Slide19Attention Deficit
People with attention deficit hyperactivity disorder tend to have difficulty focusing and maintaining attention.
People with FASDs have fewer problems with focusing and maintaining attention, but more trouble shifting attention from one task to another (what researchers call “set shifting”)
Slide20Reaction Time Deficits
Slow reaction time
Reduced brain processing speed
Both of these affect overall intelligence by limiting the brain’s capacity to take in information rapidly, particularly in a setting like an ordinary classroom.
Slide21Executive Function
One of the most limiting features:
The ability to plan for the future; and to change behavior in response to the effects of previous actions is greatly impaired
Cannot put together a sequence of actions in order to achieve a goal - for example, taking the steps necessary to complete homework or to pay a bill on time
Get “stuck” on certain things and cannot keep the whole process in mind while carrying out the steps needed to complete the task
People with FASDs are often incapable of learning from experience and thus may frequently repeat behaviors despite negative results
Slide22Poor Impulse Control
Often impulsive and may react without thinking.
Often diagnosed with
conduct disorder
and/or
oppositional defiant disorder and may have frequent run-ins with law enforcement as they appear to be willfully disobeying authorities and actively seeking repeat punishment.FASDs also appear to make people more likely to lie.
Slide23Altered Socialization
Difficulties recognizing social cues. Often “can’t take a hint,” or recognize non-verbal suggestions
Intrusiveness: excessive body contact
May be overly demanding of attention and may lack empathy towards others
Lack of stranger anxiety/too trusting
Eager-to-please and easily led and thus may be preyed upon and pushed to commit crimesTendency towards sexual promiscuity
Slide24Beyond Early Childhood
Difficulties with:
Maintaining friendships and intimate relationships
Time management (little to no concept of time)
Depression, anxiety and substance use
Inappropriate sexualityAchieving in and/or completing schoolMaintaining employmentLiving independently:High institutionalization rate in adulthoodCriminal justice system institutionalization common
Slide25Actual Age: 18
Expressive Language -----------------------------------
20
Comprehension -------
6
Money, time concepts ------- 8Emotional maturity ---- 6Physical maturity ---------------------------------- 18Reading Ability ------------------------------- 16Social Skills ---------------- 7Living Skills --------------------- 11
Vineland Adaptive Behavior Scales
Slide26Secondary Disabilities
Mental health problems – 90%
Alcohol and other drug problems - 35%
Disrupted school experiences - 61%
Juvenile justice - 60%
Confinement - 50%Repeated inappropriate sexual behaviors - 49%Streissguth, A.P., et. al. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Developmental and Behavioral Pediatrics. 2004;5(4):228-238.
Slide27Co-occurring conditions in FASD
Attention-deficit/hyperactivity disorder (ADHD)
Oppositional defiant disorder (ODD)
Conduct disorder (CD)
Reactive attachment disorder (RAD)
Sleep disordersSchizophreniaDepressionBipolar disorderSubstance use disordersPost-traumatic stress disorder (PTSD)See, e.g., Popova, S., et. al. (2016). Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis. Lancet. doi: 10.1016/s0140-6736(15)01345-8.
Slide28Protective Factors
Living in a stable and nurturing home
Being diagnosed with FAS before age six years
Having a diagnosis of FAS rather than another FASD
Never having experienced violence
Remaining in each living situation for at least 2.8 yearsExperiencing a “good quality home” from age 8 to 12 years of ageHaving been found eligible for developmental disability (DD) servicesHaving basic needs met for at least 13% of life
Streissguth, A. (1997).
Fetal Alcohol Syndrome: A Guide for Families and Communities
. Baltimore: Brookes Publishing. ISBN 1-55766-283-5;
see also
Streissguth, A.P., et. al. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects.
Developmental and Behavioral Pediatrics
. 2004;5(4):228-238.
Slide29Morgan
https://www.youtube.com/watch?v=K0VrkLQfkFg
Slide30Medical
Mental Health
Pharmacotherapy
Behavioral Therapies and Interventions
Skilled Nursing Services
Physical, Occupational, Speech TherapyEducational InterventionsEarly Intervention ServicesExceptional EdTeacher In-Service TrainingCaregiver SupportSpecial consideration for Birth MothersParent TrainingMultidisciplinary Approach Critical
Green JH. Fetal Alcohol Spectrum Disorders: Understanding the Effects off Prenatal Alcohol Exposure and Supporting Students.
Journal of School Health
. March 2007;77:103-108.
Slide31FASD Prevention Tool Kits
Developed by ACOG and CDC
www.acog.org/alcohol
Brief guide
Laminated screening
instrumentResource informationPatient handouts Pocket CardiPhone App AAP Toolkit: www.aap.org/fasd Product of AAP Division of Children with Special Needs’ Program to Enhance the Health and Development of Infants and Children (PEHDIC) award from the CDC
http://www.medicalhomeinfo.org/national/pehdic/ accessed June 2011.
Slide32Paths to AEP Prevention
Primary prevention
Women of childbearing age: assess pregnancy risk AND discuss effective contraception when appropriate
CHOICES intervention in integrated care settings
SBI in ALL adult patients
Secondary preventionSBI in ALL pregnant womenCounsel no known safe limit, safe time, or typeTertiary preventionScreen women with children for prior AEPs and provide early identification, management, and referral as needed
Slide33CHOICES: An Integrated “Best Practice” Intervention
Combines Alcohol SBI and discussion of family planning
Medical provider (medical assistant, nurse, PA, NP, DO/MD) screens and refers to masters-level counselor:
Women ages 14 to 44, drinking at risky levels AND not using effective contraception
CHOICES trained counselor provides 2 session motivational interviewing based counseling intervention
Woman chooses behavior change focus: decreasing alcohol use and/or using effective contraception (many choose BOTH)Counselor refers patient back to their clinician (PA, NP, DO/MD) to provide any desired family planning services
Slide34Keys to AEP prevention
Effective contraception, including abstinence
PRE conception care
Non judgmental: reduce STIGMA
Women with prior AEP at greatest risk for current/future AEP
“Keep It Simple”:FASDs are 100% preventableThere is no known safe amount of alcohol during pregnancy There is no safe time during pregnancy to drink There is no safe type of alcohol during pregnancy
Slide35Alcohol Use During Pregnancy
Consider that women who drink during pregnancy are likely to have experienced or be experiencing trauma:
Marker of childhood trauma
60% have experienced childhood sexual abuse
55% have experienced childhood physical abuse
42% have experienced bothMarker of current trauma(Datner, 2007) (Medrano, 1999) (Martin, 1998)
Slide36Incorporating AEP Prevention into Preconception Care
Think TERATOGEN screen
Equivalent to assessing med list for ACE-I, Retinols, other potential teratogens or occupational exposures
Two ways to address risk, if patient is using a known teratogen
Eliminate or reduce use of teratogen
Use effective contraception
Slide37Discussing AEP Prevention:
Empowering Women to Make Healthier Choices
Elicit
What do you know already about alcohol use and your health?
What birth control methods would you like more information about?
ProvideYou already know quite a bit about how alcohol effects health. What we also know about alcohol use is…To avoid an AEP, you could choose to use effective birth control methods, stop drinking or both. Other women I’ve talked with who share your concerns about that method have found…ElicitWhat do you think about that?What do you see fitting best with your life right now?What else would you like to know about that?Summarize Today we’ve talked about pregnancy prevention and alcohol use. You learned about ________. Let’s talk about the plan you’ve made.What questions do you have?
Slide38AEP Prevention Resource
Evidence-based prevention practices such as CHOICES and CHOICES-like interventions and opportunities for dissemination
Resources to help practitioners in diverse settings, ranging from high-risk settings such as mental health and substance abuse treatment centers to primary care clinics and universities, deliver interventions targeting behavior change.
Velasquez, M. M
., Ingersoll, K., Sobell, M., & Sobell, L. C. (2015). Women and Drinking: Preventing Alcohol-Exposed Pregnancies. APA Advances in Psychotherapy – Evidence-based Practices. Boston, MA: Hogrefe Press.
Slide39What is Alcohol SBI?
Screen
all adult patients for risky use of alcohol
Provide
Brief Intervention to patients at-risk of developing an alcohol use disorder (risky drinkers)39
Slide40“Traditional
”
Alcohol Screening
One question to some patients, particularly if they
“
look” like they may have an alcohol problem: Do you drink? You don’t drink do you? Non validatedTypical responses: socially, occasionally, no or CAGE
Slide41SBI Alcohol Screening: 3 Steps
Set the stage:
Address Stigma
Use evidence-based screen:
Pregnant adults: T-ACE
Provide feedback:Non drinker: Reinforce healthy choicesDrinker: Express concern, seek patient’s perspective and their permission to discuss more
Slide42Setting the Stage for Screening: Scripts Can Help
ADDRESS STIGMA
“Pregnant patients often have questions or concerns about drinking alcohol during pregnancy or before realizing they were pregnant. How about you?”
“It’s important for me in caring for you and your pregnancy that I know about your alcohol use. Tell me about your alcohol use if any since becoming pregnant, perhaps before even realizing you were pregnant?”
Slide43Valid Screen in Pregnancy:
T-ACE
T
olerance:
“How many drinks does it take to make you feel high?”
more than 2 = 2 points (0-2 = 0 points)Annoyed: “Have people annoyed you by criticizing your drinking?” yes = 1 pointCut back: “Have you felt you ought to cut back on your drinking?” yes = 1 pointEye-opener: “Have you ever had a first drink in the morning to steady your nerves or get rid of a hangover?” yes = 1 pointTotal Score (0-5): >0 = at risk
Slide44Feedback: Brief and Relevant
Reinforce healthy choices and leave “door open”
“You are making a healthy decision to not drink alcohol during your pregnancy. Let me know if you ever have any questions about alcohol and pregnancy or are concerned about the alcohol use of a loved one.”
Express concern about alcohol use in pregnancy and seek patient perspective
“
I’m concerned because alcohol use during pregnancy is unsafe. What are your thoughts about that?”Ask permission to continue discussion (transition to BI) “Is it alright if we talk a little more about this?”44
Slide45Brief Intervention
Decisional Balance
“
What do you like about drinking___?
”
“What do you not like about drinking___?”Summarize patient pros and cons, ending with consReadiness Ruler“So where does that leave you? On a scale of 0 to 10 with 0 being not at all ready and 10 being ready to make a change today, how read are you to cut back/stop drinking?”45
Score
Readiness
Stage of Change
0-3
Not Ready
Pre-contemplation; Early contemplation
4-7
Unsure
Contemplation
8-10
Ready
Preparation; Action
Slide46Readiness to Change & Intervention
46
1 2 3 4 5 6 7 8 9 10
Elicit perceived negative consequences, Express concern, Offer information, Support & follow-up
Explore motivation: why a 6 and not a 4, what would have to happen to be a 9,
Ask about next steps,
Offer support &
Follow up
Help patient develop action plan,
Identify resources,
Instill hope
Slide47Referrals & Resources
CDC FAS Home Page
www.cdc.gov/fasd
National Organization on Fetal Alcohol Syndrome (NOFAS) www.nofas.org
The National Clearinghouse for Alcohol and Drug Information www.health.org
Al-Anon, Alateen www.al-anon.alateen.orgThe National Association for Children of Alcoholics (NACoA) www.nacoa.orgNational Institute on Alcohol Abuse and Alcoholism (NIAAA) www.niaaa.nih.govSubstance Abuse and Mental Health Services Administration (SAMHSA) www.samhsa.gov47
Slide48Referrals & Resources
Early Childhood Intervention (ECI) www.dars.state.tx.us/ecis
FASD- Texas NeuroRehab Center (800)-252-5151
http://texasneurorehab.com/behavioral-treatment-for-children-and-adolescents/residential-neurobehavioral-treatment-for-children-and-adolescents/specialty-diagnoses/fetal-alcohol-spectrum-disorders/
Houston Area Partnership for FASD (HAPFASD) www.facebook.com/HAPFASDTexas Office of Prevention of Developmental Disabilities www.topdd.state.tx.usThe Arc of Texas www.thearcoftexas.orgTCH The Myers Center for Developmental PediatricsAlcoholics Anonymous (AA & NA) Houston www.aahouston.org, (713) 686-6300
48
Slide49There’
s an App for that
SBIRT App available now for Apple and Android devices
Search ‘SBIRT’
49
Slide50Questions?
Slide51BCM FASD Practice and Implementation Center - South
InSight SBIRT Residency Training Program
Acknowledgements
Roger Zoorob, MD
Sandra J Gonzalez, MSW
Alicia Kowalchuk, DOMohamad Sidani, MDLuis O Rustveld, PhD Susan Gardner Nash, PhD, MAKiara K Spooner, DPHJohn Grubb II, JDCDC-RFA-DD14-1402James Bray, PhDVicki Waters, MS, PA-CAlicia Kowalchuk, DOSubstance Abuse and Mental Health Services Administration Grant Number UT79T1020247