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FASD and Behavioral Disorders in Context: Understanding Behavior of Alcohol-Affected Children. Claire D. Coles, PhD Building State Systems Annual Meeting San Antonio, Texas June 20-22, 2005. Dr. Coles’ Affiliations.

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Fasd and behavioral disorders in context understanding behavior of alcohol affected children l.jpg

FASD and Behavioral Disorders in Context: Understanding Behavior of Alcohol-Affected Children

Claire D. Coles, PhD

Building State Systems Annual Meeting

San Antonio, Texas

June 20-22, 2005


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Dr. Coles’ Affiliations Behavior of Alcohol-Affected Children

  • Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Maternal Substance Abuse and Child Development Laboratory (MSACD)

  • Fetal Alcohol Center, Marcus Institute, Center for Developmental Disabilities


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Roger Bakeman, PhD (GSU) Behavior of Alcohol-Affected Children

Josephine V. Brown, PhD

Caroline Drews-Botsch, PhD

Arthur Falek, PhD (Retired)

Paul Fernhoff, MD

Felicia Goldstein, PhD

Julie A. Kable, PhD

Theresa Gauthier, MD

Karen Howell, PhD

Mary Ellen Lynch, PhD

Laura Namy, PhD

Kathleen A. Platzman, PhD

Mary Ann Romsky, PhD (GSU)

Biomedical Imaging Technology Center

Xiaoping Hu, PhD

Xiangyang Ma, PhD

Khalil Abdur-Rashid

John P. Berg

Felicia Berry, MA

Raemelle Edwards

Zarina Fershteyn MPH

Chris Foster

Mark Granados

Christy Hall, Ph.D.

Katrina C. Johnston, MA

Michael Marcin, MD

Tuesday Means

Lynne Padgett, PhD

Monitinique Pierre

Mark Register, PhD

Susan Schmiedling, RN

Sharron Paige-Whitaker

Geke van der Ende, MA

Colleagues2005-Emory


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Atlanta Fetal Alcohol Study Behavior of Alcohol-Affected Children

(1980-2008)

  • Low SES, Predominantly African-American

  • Identified in Prenatal Clinic based on Maternal Drinking

  • Followed Longitudinally

  • Funded: NIAAA and Georgia DHR

  • This study: N=265


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The FAS Clinic Behavior of Alcohol-Affected Children

  • A team of Professionals provides a diagnostic evaluation to assess for teratogenic effects of alcohol and drugs


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FAS Clinic Behavior of Alcohol-Affected Children

R. Dwain Blackston, MD

Shena Leverett, LCSW

Molly Millians, MEd

Betsy Meeks, RN

Jennifer Stapels, Ph.D.

Mark Register, PhD

Katrina C. Johnson, MA

Research Staff and Colleagues

Chris Cutcliffe, PhD

Elles Taddeo, EdS

Sam Maddox, MA

Lynne Padgett, PhD

Christy Hall, Ph.D.

Virtual Reality Aids

Dorothy Strickland, PhD

FAS Center Staff

Claire D. Coles, Ph.D, Director

Julie A. Kable, Ph.D. Asst. Director


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P Behavior of Alcohol-Affected ChildrenOSSIBLE MECHANISMS OF DRUGS/ALCOHOL

IN PREGNANCY:

Teratogenic (Single Factor) Model

Outcome

SIDS

Fetal wastage

Behavioral

effects

Birth Defects

Growth

retardation

Teratogenic

Substance

Fetus

Mother

Coles, 1995,


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SOME POSSIBLE MECHANISMS OF EFFECTS OF DRUGS/ALCOHOL IN PREGNANCY:

Toxic (interactive) Model

OUTCOMES

Reduced fertility

Fetal wastage

Preterm birth

Birth defects

Growth retardation

Behavior effects

Mother

Toxic

Substance

Fetus

SECONDARY OUTCOMES

Medical & behavioral

problems

SIDS

Coles, 1995


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  • OUTCOMES PREGNANCY:

  • Reduced fertility

  • Fetal wastage

  • Preterm birth

  • Birth defects

  • Growth

  • Retardation

MULTI-FACTOR MODEL

Prenatal

Environment

Social Factors

Legal Issues

Prenatal

Care

Substance Use

& Abuse

Maternal

Characteristics

Genetics

FETUS

SECONDARY OUTCOMES

  • Developmental & Medical

  • Effects

  • SIDS

MOTHER

POSTNATAL EVIRONMENT

Maternal Status/ Legal issues/ Social Factors/ Nutrition/ Substance Use Abuse/ Education / Social Services/et cetera

Coles, 1995


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The brain is the basis for: PREGNANCY:

  • Cognition (thinking)

  • Attention

  • Learning

  • Language

  • Motor Skills

  • Behavior

  • Emotion


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EFFECTS OF PRENATAL ALCOHOL PREGNANCY: EXPOSURE ON CNS

Prenatal

Exposure

CNS

RANGE OF EFFECTS

BRAIN DAMAGE

Autopsy Reports

Animal Models

MRI Studies

Mental Retardation

MBD

Animal Models

MRI

Borderline IQ

Behavioral

Attention Deficits

LEARNING DISORDERS

Longitudinal

Clinical Studies

of FAS/FAE

Exposed Children

BEHAVIOR DISORDERClinical

Reports

UNAFFECTED

Longitudinal

Clinical

Studies of

Exposed

Children


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Normal development PREGNANCY:

Conception

Birth

Post Natal Experience

Outcomes

typical

optimal

nonoptimal


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Conception PREGNANCY:

Development affected by Teratogen and by Postnatal Environment

EtOH

Birth

Post Natal Environment

Postnatal Experience

Outcomes

typical

optimal

nonoptimal


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FASD and Social Behavior PREGNANCY:

What does the research tell us?


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(Some) Secondary Disabilities Attributed to Prenatal Exposure

  • Attention Deficit Hyperactivity Disorder

  • Deficits in Executive Functioning

  • Delinquency in Adolescence

  • Substance Abuse

  • Sexual Acting Out

  • Assorted behavioral disorders


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School Failure Exposure

Impaired Judgement

Delinquency in Adolescence

Sexual Acting Out

Substance Abuse

Mental Illness

Moral Depravity

Impaired Memory

Failure to Learn from Experience

Lack of Generalization

Lying

Attachment Disorder

No Conscience

Behaviors Attributed to Prenatal Alcohol-Exposure


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Effects of Confounding Factors Exposure

Prenatal alcohol exposure

Poverty

Disability

Behavior

Disorder

Family

Dysfunction


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Problems in FAS: Clinical Samples Exposure

  • Mental Retardation/Low IQ

  • Learning Disabilities

  • Behavioral Disorders

  • Attention Deficit/Hyperactivity Disorder (ADHD)

  • Socialization

  • Academic Failure


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Mental Retardation/Low IQ Exposure

Learning Disabilities

Behavioral Disorders

Attention Deficit/Hyperactivity Disorder (ADHD)

Socialization

Academic Failure

Problems in Clinical Samples without FAS


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( ExposureNeuro) Behavioral Outcomes Examined in FASD

  • General Cognitive/Learning Skills (IQ)

  • Executive Functioning Skills

    • Attentional regulation

    • Memory,Planning and organization

  • Motor skills

  • Visual/spatial skills

  • Academic Achievement

  • Adaptive Behavior

  • Social Behavior

  • Mental Health/Behavioral Disorders


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Global Effect? Exposure

Early insults to brain result in widespread, relatively mild effects

Behavioral Phenotype”?

Specific areas of deficit attributed to exposure to specific drugs

Is there a unique “signature”?

What are the neurodevelopmental outcomes of exposure to a teratogenic agent?

  • “Heavy” Exposure?

    • Teratogenic outcomes (mortality, Dysmorphia, growth retardation, neurological damage)


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Is there a ExposureUnique Effect of Prenatal Alcohol Exposure onBehavior?

  • Can we identify neurobehavioral outcomes that are the result of prenatal alcohol exposure?

  • Is there a distinct pattern that can be used for diagnosis in the absence of knowledge of prenatal exposure?

  • Does it matter?



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Is there a distinct pattern of behavior that can be used for diagnosis in the absence of knowledge of prenatal exposure?

  • Not right now. Maybe never.


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Does diagnosis in the absence of knowledge of prenatal exposure? it Matter?

  • Yes and No

    Yes, that it would be convenient and scientifically interesting

    No, in that clinically we need to treat those who come to our attention


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Prenatal Alcohol Exposure and Behavior diagnosis in the absence of knowledge of prenatal exposure?

  • Cognition

  • Arousal Regulation and Behavior Problems

  • Social Behavior

  • Substance Abuse


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The Brain is “Plastic” diagnosis in the absence of knowledge of prenatal exposure?

  • It grows and changes with experience

  • Zero to two is the “brain growth” time

  • It is constantly “rewired” by experience

  • Learning continues over the life span

  • “education” is the method


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Functional Deficits Identified in Alcohol-Affected Individuals

  • General Cognitive/Learning Skills (IQ)

  • Executive Functioning Skills

    • Attentional/arousal regulation

    • Memory

    • Planning and organization

    • Academic Achievement

      • Math ability


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“Specific” Problems Associated with IndividualsFAS/pFAS and maybe FASD

  • Motor Problems

  • Visual-Spatial Deficits

  • Cognitive Deficits

  • Working Memory

  • Specific Academic Problems


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Problems with Motor functioning Individuals

Poor muscle tone

Use utensils

Tie Shoes

Balance

Fine motor skills

handwriting

Use of scissors

Gross motor skills

Running

Riding a bike


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Visual-Spatial Information Individuals

  • Perceiving

  • Judging

  • Storing

    --Images

    --Symbols

  • Experiencing

    --Space

    --Location


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Visual-Spatial Deficits Individuals

Difficulty judging

  • Patterns

  • Shapes

  • Relationships in space

  • Confusion over left-right

    Spatial Memory

  • Problems storing visual images in short and long term memory

  • Symbol recognition

  • Failure to use mental imagery


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“attention” IndividualsWhat is it? What’s a problem in FAS?

  • Noticing (“orienting”)

  • Arousal Regulation

  • Focusing (on the right thing)

  • Sustaining Attention

  • Encoding Information (entering it)

  • Shifting Attention (when it is time)


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Effects on Information Processing and Attention at 7 years. Individuals

  • Slower, less efficient encoding of visual information.

  • Specific Deficits in Math Skills.

Coles, et al, (1997) A comparison of children affected by prenatal alcohol exposure and attention deficit hyperactivity disorderACER, 21, 150-161


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ADHD Individuals

Problem focusing attention

Problem inhibiting impulsive behavior

High activity level and behavior problems

FAS

Problems learning information

Slower processing

Less efficient processing of visual information

Problems with flexibility in problem solving

ADHD vs. FAS


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Factors Leading to confusion re: “Attention” and “ADHD”

  • Diagnosing ADHD

  • Confusing clinical and experimental Contexts

  • Defining “attention”

  • Failing to discriminate “attention” from other cognitive constructs like “memory” and “executive functioning”



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Factors that lead to Arousal Dysregulation “ADHD”

  • Temperament

  • Brain Dysfunction

  • Hyper-reactivity to environmental events

  • Attachment difficulties

  • Environmental Events

  • Stress


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Alcohol and drug exposure: “ADHD”

Research indicates that:

  • Newborns have higher heart rates

  • Infants show more sleep disorders

  • More problems in self-consoling

  • Arousal regulation and attention

  • Difficulties with self-regulation and Aggression at 24 months


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Optimal “Arousal” Levels “ADHD”

  • There is an optimal “arousal level” for various human activities (e.g., sleep, attention, activity).

  • There is an optimal level for each person (experienced as affect state)

  • We strive to achieve this optimal level (e.g., coffee, food, music, alcohol, physical arousal, exercise, etc)


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Does alcohol exposure predispose a child to later drug abuse?

  • 30 - 40% of FAS/pFAS population reported alcohol and other drug abuse problems, ages 12 - 20; for ages 21 - 51, 30 to 70%.

    (Streissguth, 1996).


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Does alcohol exposure predispose a child to later drug abuse?

  • Lower rates than national sample: 71% of 10th graders vs. 50% of FAS/pFAS sample of 15 year olds reported “any use” of alcohol

  • Lower rates of cigarette use: 58% national sample vs. 29% of FAS/pFAS

  • Illicit drug use was very rare among our 15 year olds

Coles, et al. , 1999


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Does Alcohol Exposure Predispose A Child to Delinquent Behavior?

  • 60% of FAS/pFAS clients experienced trouble with the law (Streissguth, 1996)

  • Prenatal exposure associated with delinquency and criminal behavior (Fast et al., 1999)


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High Levels of Delinquency May Not be Typical of Most Adolescents with FAS

  • Many of these studies have been completed based on samples of teens who already have been referred for professional services because of behavioral problems

  • These teens are probably the most severely affected and not representative of the broader spectrum of alcohol-affected adolescents


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Predictors of Delinquency: Atlanta FAS Sample Adolescents with FAS

  • Externalizing behaviors

  • Self-reported substance abuse

  • Higher number of negative life events

  • Lack of supervision

  • Inconsistent discipline provided by caregivers


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Source: Lynch, et al. (2003) Examining delinquency in adolescents differentially prenatally exposed to alcohol.J Stud Alcohol, 64, pp. 678-686

It is widely reported that prenatal alcohol exposure is associated with later “criminal” behavior.

But most studies didn’t controlled for environmental factors.


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Conclusions: FAS and Delinquency adolescents differentially prenatally exposed to alcohol.

  • Delinquent behavior more strongly related to current environmental factors such as stressful life events and parental characteristics and behavior than to prenatal exposure to alcohol

  • Important to examine current family, peer and community influences in addition to exposure status


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