Transcript Fetal Alcohol Spectrum Disorder: Assessment & Strategies Stade 2008 www.faseout.ca Outline • Introduction • Early Identification and Assessment – – – • Diagnostic guidelines and assessment Screening Rational for early diagnosis Cognitive, Behavioral, Social.

Fetal Alcohol Spectrum Disorder:
Assessment & Strategies
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Outline
•
Introduction
•
Early Identification and Assessment
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–
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•
Diagnostic guidelines and assessment
Screening
Rational for early diagnosis
Cognitive, Behavioral, Social Development and
Nutrition of Children, Birth to Age 6 years
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–
Issues and Strategies
Focus on Families
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Introduction
• In Canada the
incidence of Fetal
Alcohol Spectrum
Disorder (FASD) has
been estimated to be
1 in 100 live births.
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Introduction
• Caused by prenatal exposure to alcohol.
• FASD is the leading cause of developmental
and cognitive disabilities among Canadian
children.
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Introduction: Fetal Alcohol
Spectrum Disorder Defined
• Growth Restriction
• Facial Anomalies
• CNS Dysfunction
• Prenatal Alcohol
Exposure
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Introduction
• Cost of FASD annually to Canada of those 1 to
21 years old, was $344,208,000 (95% CI
$311,664,000; $376,752,000).
• (Stade, 2004).
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Introduction: Etiology
• Alcohol readily crosses the placenta and results
in similar levels in the mother and fetus
• Rate of elimination is slower in the fetus
• Most teratogenic effect during organogenesis
and development of the nervous system
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Etiology
• When neuronal activity is abnormally suppressed
during the developmental period, the timing and
sequence of synaptic connections is disrupted,
and this causes nerve cells to receive an internal
signal to commit suicide, a form of cell death
known as "apoptosis".
•
Addiction Biology 2004 Jun;9(2):137-49.
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Etiology
• Teratogenesis is grossly dose related, although
the threshold dose is still unknown and related
to maternal/fetal susceptibility.
• Risk to fetus greatest with more than 7 standard
drinks per week (1 standard drink = 13.6 grams
of absolute alcohol).
• Binge drinking of more than 5 ounces (142
grams) per occasion vs. 4 or more drinks per
occasion.
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Standard drinks = 0.5 oz alcohol
12 oz (341 mL) can of beer (5% alcohol)
12 oz (341 mL) bottle of cooler (5% alcohol)
5 oz (142 mL) glass of wine (12% alcohol)
1.5 oz (43 mL) distilled spirits (40% alcohol)
3 oz (85 mL) fortified wine e.g. sherry or port
(18% alcohol )
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Etiology
• No safe time to drink during pregnancy
• No known safe amount
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Risk Factors
• Maternal Age and Parity
• Chronicity of Alcoholism
• Socioeconomic Status
• Polydrug Use
• Ethnicity
• Fetal Susceptibility
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Diagnostic Guidelines
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Important Features of Diagnostic
Guidelines
• Minimize false negatives and false positives
• Precisely define diagnostic criteria
• Consider genetic and family histories
• Multidisciplinary approach
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Rational for Early Diagnosis
• Accurate and timely diagnosis is essential:
– to improve outcomes
– decrease risk of secondary disabilities
– increase opportunities for prevention
– ensure more accurate estimates of incidence
and prevalence
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Canadian Guidelines for
Diagnosis CMAJ, March 2005
• The Diagnostic Process
– Screening and referral
– Physical exam and differential diagnosis
– Neurobehavioural assessment
– Treatment and follow-up
• Team members
– Program director/Co-ordinator
– Physician (trained in diagnosis)
– Psychologist
– Social worker
– OT, Speech, psychiatrist, geneticist, addiction worker,
community support workers, teachers etc.
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Canadian Guidelines for
Diagnosis
• Physical Exam
• General physical to rule out other disorders
• Growth (at or below 10th percentile)
• Facial features
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Growth Restriction
• Growth restriction is demonstrated by height and
weight at or below the tenth (10th) percentile
• Growth restriction may be apparent prenatally
and/or postnatally
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Facial Features
• Short palpebral fissures
• Smooth or flat philtrum
• Thin upper lip
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Facial Features
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Associated Anomalies
• Cardiac anomalies
• Joint and limb anomalies
• Neurotubal defects
• Anomalies of the urogenital system
• Hearing disorders
• Visual problems
• Severe dental malocclusions
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Canadian Guidelines for Diagnosis
-Neuro-behavioural Assessment
• Domains to be assessed by psychologist or
team:
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Hard and soft neurological signs
Brain structure
Cognition (IQ)
Communication
Academic achievement
Memory
Executive functioning
Attention deficit/hyperactivity
Adaptive behaviour, social skills, social communication
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Early Infancy
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Tremors
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Poor suck
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Hypotonic/Hypertonic
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Irritability
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Feeding problems
•
Developmental delay
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Early Childhood
• Cognitive Problems
• Sensory Dysfunction
• Motor Issues
• Speech Delay
• Behavioral
Presentation
• Hyperactivity
• Socialization
Difficulties
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Canadian Guidelines for Diagnosis
Maternal Alcohol History in Pregnancy
• Key to establishing an accurate diagnosis
• Require confirmation based on clinical records,
self-report, reliable observation
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Classification of FASD
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Fetal Alcohol Syndrome (FAS)
•
Partial Fetal Alcohol Syndrome (PFAS) with
confirmed maternal alcohol exposure
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Alcohol-Related Neuro-Developmental
Disorder (ARND) with confirmed maternal
alcohol exposure
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Diagnostic Criteria
FAS
• Evidence of growth impairment
• 3 facial anomalies
• 3 central nervous system domains impaired
• Confirmed or unconfirmed alcohol
exposure
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Diagnostic Criteria
Partial FAS
• 2 facial anomalies
• 3 central nervous system domains impaired
• Confirmed alcohol exposure.
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Diagnostic Criteria
ARND
• 3 central nervous system domains impaired
• Confirmed alcohol exposure.
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Screening
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Screening and Primary Care
Referral
Referral of individuals to FASD diagnostic clinics:
• Evidence of prenatal exposure to alcohol
(or probable) with suspected or confirmed
CNS dysfunction or
• Presence of 3 characteristic facial features
with growth deficits with or without known
prenatal alcohol exposure.
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Conclusion
• Diagnosis requires a multi-disciplinary approach
• Diagnosis is complex and guidelines are well
defined and cannot be a gestalt approach
• Confirmed prenatal alcohol exposure is required
for a diagnosis of Partial FAS and ARND
• Screening does not equate to diagnosis.
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Cognitive, Behavioral, Social
Development and Nutrition of Children
from Birth to Age 6
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Cognitive
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Cognition
• Attention problems and memory deficits often
make learning difficult in the young child.
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Cognition
• Infants and young children with FASD live with
differing levels of cognitive abilities
• All programs to develop cognitive abilities should
be child specific.
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Cognition
• How does the individual child with FASD
learn?
Some are primarily visual learners, some are
tactile learners, some kinesthetic, and some
learn best by listening.
(Mountford,A. The Golden Hoop of Life).
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Cognition: Strategies
• If a child learns best through music …
• If a child learns through body movement …
• If a child learns best through listening …
• If a child is a tactile learner …
(Mountford, A. The Golden Hoop of Life).
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Cognition: Strategies
• May need to use short sentences
• Break down information and instruction
• Repetition, Repetition, Repetition
• Teach one concept at a time.
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Cognition: Strategies
• “ It took him four weeks at age four to learn the
colour red. We decided in February he was
going to learn his colours. So everyday of the
month I dressed him in red.
The teacher had to say ‘X you’re wearing a red
shirt today. Show me your shirt. It’s red’. ‘X
you’re wearing red pants today’. Something had
to be red”.
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Cognition: Strategies
• Treasure hunts
• Problem-solving activities
• Visual-spatial games
• Story building
• Math skills: visual teaching
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Cognition
Impacting on the development of cognitive skills
is the child’s ability to process their sensory
world.
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Sensitivity
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Sensory Processing
Many infants and young children
with FASD have difficulty processing and
organizing sensory information they receive from
their own bodies and the outside world.
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Sensory Processing
• Sensory processing is a developmental process
• Takes place in the central nervous system
• Involves ability to take in information
through the senses, organize it in our brains and
use it to respond appropriately
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Sensory Processing
The brain must properly process information
from the senses to develop:
– concentration
– organization
– learning ability
– specialization of each side of the body and
brain
– self-esteem
– self-control
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Sensory Processing
How does sensory processing abilities impact on
day-to-day life of a child with FASD?
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Normal Sensory Integration
• Schwab, D. (2001).
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Sensory Processing
• Hypersensitive
– Touch (Touch Processing)
– Noise (Auditory Processing
– Visual Input (Visual Processing).
• Dysfunction in Behavioural Outcomes of
Sensory Processing.
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Sensory Processing Strategies
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Place your child first or last in line
Wash clothes a couple of times before wearing
Use soft bedding
Remove tags from clothes
Avoid:
– ties under the chin
– thick seams in clothing
– clothes that are scratchy
• Avoid tickling
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Sensory Processing Strategies
• Weighted Vests
• Deep Massage
• Bear Hugs
• Activities using a number of muscles groups
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Sensory Processing Strategies
• Tone down the room’s effects on all senses
• Avoid decorated rooms
• Walls should be single colour and very pale
• Avoid clutter
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Sensory Processing Strategies
• Provide a place/space where the child can have
a “quiet place” to be
• Avoid crowds and places with many people, lots
of noise and high activity level
• At daycare, preschool, and school group activity
should avoid large groups
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Sensory Processing Strategies
• Group play – use little mats
• Recognize why a child may refuse to participate
in a game
• Occupational Therapy
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Sensory Processing
Hyposensitive
– Pain
– Hot or Cold
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Strategies: Hyposensitive
• Supervision
• Avoid overdressing in summer
• Ensure dressed adequately in winter
• Ensure child monitored and receives adequate
care when ill
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Behaviours
Behavioural and Emotional Responses may
reflect the child’s outcomes of sensory
processing.
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Behaviour: Hyperactivity
Due to the child’s sensory processing difficulties
he or she may have a constant need for activity.
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Strategies
• Fidget Items
• Short periods of
sitting still
• Teaching during
activity
• Music
• Hammock
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Difficult Behaviours
• What is needed is a change in thinking from
discipline to redirection or re-teaching
• Prevention – sensory strategies,
transitioning
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Strategies
• Be firm but supportive
• Choose one or two critical behaviors at a time to
work on
• Ignore minor negative behaviour
• Keep the mood positive. Give five times
more praise to every one correction.
• Identify warning signs re: “melt down”
• Teach child to self-monitor
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Difficult Behaviours
Calming strategies:
– Comfort corner
– Tents and caves
– Very short time outs
– Deep pressure
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Crying: Infancy
• Crying is an infant’s way of expressing his/her
needs
• Infants prenatally exposed to alcohol may seem
like they are crying constantly
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Crying: Infancy
• Avoid, if you can, letting a baby get to a state of
frantic crying
• Get to know strategies that work best, and tell
other caregivers how the baby likes to be
handled.
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Crying: Infancy
• Wrap the infant snugly in a receiving blanket –
when not sleeping
• Use a soother
• Bathing may settle some, quiet music may help
others
• Rocking the infant up and down rather than back
and forth has been found to be soothing for
some infants.
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Crying: Young Child
• Crying is a method of communication for all
young children
• In the child with FASD be alert for:
• sensory overload
• inability to communicate
• mood problems
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Crying: Young Child
• Modify environment
• Ensure child can communicate needs – pictures,
sign language
• Assessment by a mental health professional
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Health & Illness
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Health and Illness
Generally, FASD is not defined by associated
physical disability or illness.
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Health & Illness
Some children with FASD are born with organ
anomalies.
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Organ Anomalies
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Cardiac anomalies
Joint and limb anomalies
Neurotubal defects
Anomalies of the urogenital system.
Hearing disorders
Visual problems
Severe dental malocclusions
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Health & Illness
Zhang and others (2005) demonstrate the
adverse effects of alcohol on immune
competence and the increased vulnerability of
ethanol-exposed offspring.
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Health & Illness
• The infant should not be exposed to
environmental irritants such as tobacco smoke
• Protect the infant from exposure to viruses.
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Health & Illness
• Young children with FASD are particularly prone
to upper respiratory illnesses and ear infections
• Monitoring and ensure treatment as necessary
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Health & Illness
Motor deficits are not uncommon in infants and
young children with FASD
– Infant & Pre-school stimulation programs
– Occupational Therapy
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Sleep
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Sleep Disturbances
• Sleep disturbances among individuals with
FASD are not uncommon
• Younger children often have trouble falling
asleep and waking
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Sleep Disturbances
• They may have trouble settling and wake often
throughout the night
• Night terrors among individuals with FASD can
continue throughout life
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Sleep Strategies
• Establish rituals for saying good night
• Start a calming bedtime routine an hour before
bedtime
• A light snack before bed may be beneficial for
some children
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Sleep Strategies
• Decrease sensory stimulation in the bedroom
• White noise when the child is in bed may be
calming to some but distracting to others
• Night-lights help some young children but for
some can lead to night terrors
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Sleep Strategies
• Start young to promote the child sleeping in his
or her own bed
• Melatonin may be beneficial
• Childproof the house for night wanderers
• As much as possible wake the child in the same
predictable way every morning
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Nutrition
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Growth and FAS
 Unsure of the effect of alcohol on growth
parameters later on in life.
 Substantial literature on the association
between maternal alcohol consumption during
pregnancy and decreased neonatal weight,
length and head circumference
McFadyen, K. (2005)
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Studies: Growth and FASD
Russell (1991)
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Differences in head circumference and ht at
6 years
Sampson (1994)
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No detectable differences from 8 mos to 14
years
Day (2002)
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1st trimester exposure predicted significant
reductions in wt, HC, and length
2nd trimester exposure predicted significant
reductions in wt and skinfold thickness
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Nutrition and FASD
• Infants and young children with
FASD must have there growth
followed regularly
• Those with poor growth/growth
restriction should be followed by a
dietician
• Motor dysfunction resulting in poor
suck and swallow requires OT
intervention
• “Picky eaters” requires patience,
persistence, and imagination.
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Essential Fatty Acids
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What we know….

Essential fatty acids (EFA) are
necessary for the formation of
healthy cell membranes, proper
development and function of the
brain and nervous system –

Omega 3 and Omega 6 fatty
acids must be provided from food
as they cannot be synthesized by
the body.
McFadyen, K. (2005)
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ESSENTIAL FATTY ACIDS
OMEGA 3 FATTY ACIDS
Green leafy vegetables,
flax, flaxseed oil, canola
oil, walnuts, Brazil nuts,
fish oil, fish, tofu, and
eggs
OMEGA 6 FATTY ACIDS
Vegetable oils
(soybean, safflower,
and corn oil), nuts and
seeds
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What we know continued…
Some evidence indicates that
fatty acid deficiencies or imbalances may
contribute to the negative sequelae of some
childhood neuro-developmental disorders.
McFadyen, K. (2005)
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EFA Supplementation
1. There have been no studies to date looking at
EFA supplementation and children with FASD
2. Some studies have demonstrated the benefits
of EFA in children with other neurodevelopmental disorders – but other research
have found no effect
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Thoughts…..
1. Pregnancy stresses maternal EFA status
because the mother must supply fatty acids
needed for fetal and placental growth.
2. Alcohol can disturb placental transport.
3. Alcohol increases fatty acid catabolism –
resulting in ???
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What we do not know….
1. Whether supplementation of essential fatty
acids may benefit in children with FASD
2. Optimal dosage of fatty acids
3. Optimal composition (Omega 3 and Omega 6
fatty acids)
4. Dose – response relationship
5. Duration or treatment
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In the End……
• Encourage the young child with FASD to eat a
variety of foods from the four food groups
• To increase intake of EFA’s offer fish, eggs, nuts,
seeds and use vegetable oils
• Monitor growth
McFadyen, K. (2005)
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Social Skills & Friendships
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Social Skills and Friendships
• Social skill development should begin early for
children with FASD
• Distractibility, aggressiveness and, and
impulsivity can interfere with social development
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Social Skills and Friendships
• Social skills program
– Practice, model, rehearse social skills
• Foster activities that the child likes and is good
at
• Brief activities in small groups
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Social Skills and Friendships
• Invite other children to the home and adapt the
situation so it is fun for the other children
• Educate young children that they may learn or
respond to situations or stimuli somewhat
differently than others
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Caregivers
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Strategies for Caregivers
• Keep remembering they are not willfully trying to
make you exhausted or crazy
• Forgive yourself when you lose your temper
• Allow yourself to grieve
• Advocate for their needs
It will make you feel better about them and
yourself.
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Strategies for Caregivers
• Do something for yourself every day
• Find someone you can talk to
• Try to get in as many breaks as possible –
friends, family, respite
• Monitor yourself for signs of increased stress
and depression
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Thank-You!
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