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Presentation for the Cree Nation Kent Saylor, MD January 15, 2013. Fetal Alcohol Spectrum Disorder. Introduction. Pediatrician Mohawk Nation Montreal Children’s Hospital, Northern and Native Child Health Program Visiting the Cree communities since 2000

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Presentation for the cree nation kent saylor md january 15 2013

Presentation for the Cree Nation

Kent Saylor, MD

January 15, 2013

Fetal Alcohol Spectrum Disorder


Introduction
Introduction

  • Pediatrician

  • Mohawk Nation

  • Montreal Children’s Hospital, Northern and Native Child Health Program

  • Visiting the Cree communities since 2000

  • Became interested in FASD due to large number of referrals


Child 1
Child #1

  • 11 year old boy, grade 6

  • Born prematurely

  • Problems in school

    • Poor attention span

    • Not learning well

    • Hard time making friends

  • Normal growth and appearance

  • Confirmed alcohol exposure in utero


Child 2
Child #2

  • 11 y/o boy

  • Been in and out of foster care

  • Problems at school

    • Poor concentration

    • ? memory problems

    • Some social difficulties

  • Face – mild abnormalities

  • Confirmed alcohol exposure in utero


Child 3
Child #3

  • 7 year-old boy

  • Hard to manage at home

    • Single dad, hard to set limits

  • Hard to manage at school

    • Hyperactive, can’t sit still

    • Not learning well

  • Normal growth and appearance

  • Confirmed alcohol exposure in utero



Terminolgy
Terminolgy exposure in utero?

FASD

Fetal Alcohol Syndrome

(FAS)

Alcohol-related

Neurodevelopmental

Disorder

(ARND)

Partial Fetal Alcohol

Syndrome

(pFAS)


“FASD” is not a diagnosis exposure in utero?


Older terms
Older terms exposure in utero?

FAE

ARBD


FASD exposure in utero?

  • There are strict criteria for diagnosis for all 3 official diagnoses

    • Growth

    • Facial features

    • Brain damage*

    • Alcohol use during the pregnancy*


FASD exposure in utero?

  • All children with FAS, pFAS or ARND have:

    • Alcohol exposure during the pregnancy

    • Brain damage

  • This is a life-long condition!!


Brain damage
Brain Damage exposure in utero?

ARND = pFAS = FAS

http://minnesota.publicradio.org/display/web/2007/09/06/fasd6

http://www.fascme.com/c104.php


Most common diagnosis
Most common diagnosis exposure in utero?

The majority of children affected by alcohol exposure have ARND and look totally normal!


Diagnosis of fasd
Diagnosis of FASD exposure in utero?

  • There is no blood test or x-ray to detect FASD

  • The diagnosis is made by the evaluation of a specialized team including the following:

    • Doctor

    • Psychologist (neuropsychologist)

    • Occupational Therapist

    • Speech and Language Pathologist


Multidisciplinary team approach
Multidisciplinary Team Approach exposure in utero?

Ideally the team evaluates the child over several days, comes to a conclusion together about the diagnosis and gives the information and recommendations to the family.


Diagnostic team for fasd
Diagnostic Team for FASD exposure in utero?

  • Doctor

    • Must have knowledge about FASD

    • Know the criteria for FASD

    • Extra training for diagnosis

    • Be competent in making the measurements

    • Cannot make the diagnosis alone


Diagnostic team
Diagnostic team exposure in utero?

  • Psychologist

    • Have knowledge about FASD

    • Know the criteria for FASD

    • Extra training for diagnosis

    • Be able to test all brain domains for evidence of brain damage

    • Cannot make the diagnosis alone


  • Occupational Therapist exposure in utero?

    • Must have knowledge about FASD

    • Know the criteria for FASD

    • Extra training for diagnosis

    • Know which tests to use

    • Cannot make the diagnosis alone


  • Speech and Language Pathologist exposure in utero?

    • Must have knowledge about FASD

    • Know the criteria for FASD

    • Extra training for diagnosis

    • Know which tests to use

    • Cannot make the diagnosis alone


Barriers to diagnosis
Barriers to diagnosis exposure in utero?

There is no multidisciplinary diagnostic clinic in Quebec!


Barriers to diagnosis quebec
Barriers to diagnosis - Quebec exposure in utero?

  • Doctors and psychologists

    • Most are not qualified to do an evaluation

    • Most have not taken the extra training

    • Most do not know the exact criteria

    • Most do not know who to refer to

    • Some may try to make the diagnosis alone which can be dangerous


Barriers to diagnosis quebec1
Barriers to diagnosis-Quebec exposure in utero?

  • Occupational Therapists and Speech and Language Pathologists

    • Most have not taken the extra training

    • Most do not know the exact criteria

    • Most do not know what to test for


Cree territory barriers
Cree Territory - Barriers exposure in utero?

  • Current status

    • Poor documentation of alcohol use in the medical records of the birth mom

    • Incomplete birth records from hospital where mom’s are delivering

    • Many children in foster care and alcohol history is unknown. Youth protection workers finding it hard to get this info.

    • Denial of alcohol use


Cree territory barriers1
Cree Territory - Barriers exposure in utero?

  • Speech and Language Pathology

    • None in the territory for children 0-5 years

    • None have the expertise to evaluate children for FASD

  • Occupational Therapy & Psychology

    • Limited resources in the territory

    • None have the expertise to evaluate children for FASD


Cree territory barriers2
Cree Territory - Barriers exposure in utero?

  • Doctors

    • Most do not know about FASD

    • Most do not know who to refer to

    • Some are not making the referrals because they do not feel there are adequate resources to help a child with FASD!


Resources needed
Resources needed! exposure in utero?


Diagnostic team1
Diagnostic Team exposure in utero?

  • A diagnostic team is needed

  • We are currently evaluating the children by individual assessments and not using a team approach

  • We are working with the Cree Nation to find a solution


Resources in the communities
Resources in the communities exposure in utero?

  • There are many entities who must be involved in raising children with FASD

    • Parents

    • Schools

    • Health care

    • Daycare

    • Others

  • Currently none of these services are properly equipped for a child with FASD


Schools
Schools exposure in utero?

  • The school is often the main service for children with FASD

    • Most children diagnosed are school age

    • Children spend the majority of their time at school

    • These children are already in your schools


Schools1
Schools exposure in utero?

  • There are models for success but there is no well-defined treatment for children with FASD

  • Individualized approach for each child

  • Some commonalities


School services
School services exposure in utero?

  • Requires some professionals present at all times in the schools

  • The model of bringing specialists in for consultation and then leaving the community will likely not work

  • Parents will likely need to be involved with their children at school


School services1
School services exposure in utero?

  • Suggestions for success

    • Training/education for teachers and professionals

    • Learn new techniques for teaching children with FASD

    • Small class size

    • Low stimulation classrooms


School professionals
School professionals exposure in utero?

  • Behavioural specialists available daily (psychoeducator or other professional)

  • Frequent visits by speech and language pathologist

  • Availability of school psychologist several times per year


Schools communication
Schools -Communication exposure in utero?

  • Teachers will need close contact with:

    • Parents

    • Health care professionals

    • Social Services


Schools funding
Schools - Funding exposure in utero?

  • More funding is required

    • Coding

      • Encourage parents for evaluations

  • Fundraising

  • Direct funding from Minister of Education

  • Networking with other Cree entities


Health board
Health Board exposure in utero?


Health board1
Health Board exposure in utero?

  • Professionals who know children are desperately needed

  • Professionals hired for adults and children will probably focus on the adults


Health board priorities
Health Board Priorities exposure in utero?

  • Professional who can assist families of children with behavioural challenges are desperately needed

  • Speech and Language pathology for children must be available in all communities

  • Occupational therapy for children must be available in all communities

  • Child Psychology services


Health board priorities1
Health Board priorities exposure in utero?

  • Case Managers will be needed for these children

    • Advocates for the children

    • Helping to support the families

    • Assist with communication among all services involved

    • Follow the child into their adult life

    • Could be social worker, OT, nurse, psychologist, etc.


Dyp social services
DYP/Social Services exposure in utero?

  • These children need a stable home

  • Shifting the child from one home to another is probably making things worse


Dyp social services1
DYP/Social Services exposure in utero?

  • DYP Workers

    • Know how to ask your clients about alcohol use during the pregnancy

    • Know what to tell them if they are using alcohol or their child was exposed

    • Document, document, document!!!


Daycares cra
Daycares/CRA exposure in utero?

  • Most child are not diagnosed until after starting kindergarten

  • Already working with several children with special needs

  • Workers with early childhood education

  • Role is to identify children at risk and suggest a referral


Chb csb cra
CHB-CSB-CRA exposure in utero?

  • FASD awareness and prevention

  • Recruitment and retention of professionals

  • Additional funding is probably needed, work together

  • Communication and resource sharing is important

  • Avoid silo approach


Resources and funding
Resources and funding exposure in utero?

Silo Approach


Resources and funding1
Resources and Funding exposure in utero?

Combined approach


Chb csb cra1
CHB-CSB-CRA exposure in utero?

  • The families will be the main caregivers for this child for the rest of their lives

    • Support

      • Financial

      • Parenting skills

      • Life skills

      • Respite

      • Academic

      • Etc.


Back to the cases
Back to the cases exposure in utero?


Child 11
Child #1 exposure in utero?

  • 11 year old boy, grade 6

  • Born prematurely

  • Problems in school

    • Poor attention span

    • Not learning well

    • Hard time making friends

  • Normal growth and appearance

  • Confirmed alcohol exposure in utero


Child 12
Child #1 exposure in utero?

  • Eventually diagnosed with ARND - 2 years after first meeting

  • School modified plan, resources obtained

  • Responded to medications for ADD

  • Family continues to struggle with parenting and stability

  • Child now in group home and not doing well.


Child 21
Child #2 exposure in utero?

  • 11 y/o boy

  • Been in and out of several foster homes

  • Problems at school

    • Poor concentration

    • ? memory problems

    • Some social difficulties

  • Face – mild abnormalities

  • Confirmed alcohol exposure in utero


Child 22
Child #2 exposure in utero?

  • Completed all the testing after 10 months

  • Does not fit criteria for FAS, pFAS or ARND

  • Confirmed ADHD

  • Doing well in stable foster family


Child 31
Child #3 exposure in utero?

  • 7 year-old boy

  • Hard to manage at home

    • Single dad, hard to set limits

  • Hard to manage at school

    • Hyperactive, can’t sit still

    • Not learning well

  • Normal growth and appearance

  • Confirmed alcohol exposure in utero


Child 32
Child #3 exposure in utero?

  • Still awaiting for a full evaluation after 18 months

  • Family has missed several appointments

  • No family stability, child goes off and on meds for ADHD

  • Not getting services

  • Cannot get a straight answer of how he is doing at school


Conclusion
Conclusion exposure in utero?

  • FASD is not a diagnosis

  • The 3 accepted terms are FAS, pFAS and ARND

  • All three are equally severe in terms of brain damage


Conclusions
. . . conclusions exposure in utero?

  • Diagnosis is challenging

  • The process to make a diagnosis is currently not ideal

  • We are working on a plan to create a multidisciplinary team


Conclusions1
. . .conclusions exposure in utero?

  • The children and parents will need multidisciplinary support in the communities for life


Conclusions2
. . . conclusions exposure in utero?

  • Major changes will need to take place to identify and support these children and their families

    • Cree School Board

    • Cree Health Board

    • Cree Regional Authority

    • Other



Thank you
Thank you exposure in utero?


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