# Presentation: 213781

## 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

- 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

## Colleagues2005-Emory

**Roger Bakeman, PhD (GSU)**
**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**

## Atlanta Fetal Alcohol Study

-  (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

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

**The FAS Clinic**

## FAS Center Staff

- FAS Clinic
- 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

**Claire D. Coles, Ph.D, Director**
**Julie A. Kable, Ph.D. Asst. Director**

## POSSIBLE MECHANISMS OF DRUGS/ALCOHOL 

**P****OSSIBLE ****M****ECHANISMS OF ****D****RUGS/****A****LCOHOL **
**IN ****P****REGNANCY: **
**Teratogenic (Single Factor) ****M****odel**

**Teratogenic**
**Substance**

**Fetus**

**  ****Outcome**
**SIDS**
** ****Fetal wastage**
** ****Behavioral **
**   ****effects**
** ****Birth Defects**
** ****Growth**
**   ****retardation**
** **

**Coles, 1995,**

**Mother**

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

**Toxic (interactive) Model**

**Toxic**
**Substance**

**Mother**

**Fetus**

**OUTCOMES**
**Reduced fertility**
**Fetal wastage**
**Preterm birth**
**Birth defects**
**Growth retardation**
**Behavior effects**

**SECONDARY OUTCOMES**
**Medical & behavioral**
**problems**
**SIDS**

**Coles, 1995**

## MULTI-FACTOR MODEL

** ****Prenatal **
** ****Environment**
** ****Social Factors**
** ****Legal Issues**
** ****Prenatal **
** ****Care**
** ****Substance Use **
**  ****& Abuse**
** ****Maternal **
** ****Characteristics**
** ****Genetics**

***OUTCOMES***
** ****Reduced   fertility**
** ****Fetal wastage**
** ****Preterm birth**
** ****Birth defects**
** ****Growth **
**  ****Retardation****    **

**MOTHER**

** **FETUS

***SECONDARY OUTCOMES***

** ****Developmental & Medical**
**  ****Effects**
** ****SIDS**

***POSTNATAL EVIRONMENT***

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

**MULTI-FACTOR MODEL**

***Coles, 1995***

## The brain is the basis for:

- Cognition (thinking)
- Attention
- Learning
- Language
- Motor Skills
- Behavior
- Emotion

## EFFECTS OF PRENATAL ALCOHOL EXPOSURE ON CNS

**Autopsy Reports**
**Animal Models**
**MRI Studies**
**Mental Retardation**

**EFFECTS OF PRENATAL ALCOHOL ****EXPOSURE ON CNS**

**Prenatal**
**Exposure**

**CNS**

_**MBD**_
**Animal Models**
**MRI**
**Borderline IQ**
**Behavioral**
**Attention Deficits**

_**LEARNING DISORDERS**_
**Longitudinal**
**Clinical Studies**
**of FAS/FAE**
**Exposed Children**

_**BEHAVIOR DISORDER**_**Clinical **
**Reports**

_**UNAFFECTED**_
**Longitudinal**
**Clinical**
**Studies of **
**Exposed**
**Children**

**RANGE OF EFFECTS**

## Normal development

**Normal development**

- Conception

- Birth

- nonoptimal

- optimal

- typical

- Outcomes

- Post Natal Experience

## Development affected by Teratogen and by Postnatal Environment

**Development affected by Teratogen and by Postnatal Environment**

- Conception

- Birth

- nonoptimal

- optimal

- typical

- Outcomes

- Post Natal Environment

- EtOH

- Postnatal Experience

## FASD and Social Behavior

- What does the research tell us?

## (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

## Behaviors Attributed to Prenatal Alcohol-Exposure

- School Failure
- 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

## Effects of Confounding Factors

- Poverty

- Disability

- Behavior
- Disorder

**Prenatal alcohol exposure**

**       ****Family **
**Dysfunction**

##  Problems in FAS: Clinical Samples

- Mental Retardation/Low IQ
- Learning Disabilities
- Behavioral Disorders
- Attention Deficit/Hyperactivity Disorder (ADHD)
- Socialization
- Academic Failure

## Problems in Clinical Samples without FAS

- Mental Retardation/Low IQ
- Learning Disabilities
- Behavioral Disorders
- Attention Deficit/Hyperactivity Disorder (ADHD)
- Socialization
- Academic Failure

## (Neuro) 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**

## Is there a unique “signature”?

- Global Effect?
- Early insults to brain result in widespread, relatively mild effects

- Behavioral Phenotype”?
- Specific areas of deficit attributed to exposure to specific drugs

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

- “Heavy” Exposure?
- Teratogenic outcomes (mortality, Dysmorphia, growth retardation, neurological damage)

## Is there a Unique Effect of Prenatal Alcohol Exposure on Behavior?

- 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?

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

- Yes

## 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.

## 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

- 		Yes, that it would be convenient and scientifically interesting
- 		No, in that clinically we need to treat those who come to our attention

- Does it Matter?

## Prenatal Alcohol Exposure and Behavior

- Cognition
- Arousal Regulation and Behavior Problems
- Social Behavior
- Substance Abuse

## The Brain is “Plastic”

- 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

## 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**

## “Specific” Problems Associated withFAS/pFAS and maybe FASD

**Motor Problems**
**Visual-Spatial Deficits**
**Cognitive Deficits**
**Working Memory**
**Specific Academic Problems**

## Problems with Motor functioning

- Poor muscle tone
- Use utensils
- Tie Shoes
- Balance
- Fine motor skills
- handwriting
- Use of scissors
- Gross motor skills
- Running
- Riding a bike

## Visual-Spatial Information

**Perceiving**
**Judging**
**Storing**
**	****--Images**
**	****--Symbols**
**Experiencing**
**	****--Space**
**	****--Location**

## Visual-Spatial Deficits

**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**

## “attention”What 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)

## Effects on Information Processing and Attention at 7 years.

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

- Slower, less efficient encoding of visual information.
- Specific Deficits in Math Skills.

## ADHD vs. FAS

_**ADHD**_
**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 **

## 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”

## Understanding Arousal Dysregulation

## Factors that lead to Arousal Dysregulation

- Temperament
- Brain Dysfunction
- Hyper-reactivity to environmental events
- Attachment difficulties
- Environmental Events
- Stress

## Alcohol and drug exposure:

- 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

## Optimal “Arousal” Levels

- 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)

## 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).

## 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

## 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)

## 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

## Slide 45

## Predictors of Delinquency: Atlanta FAS Sample

- Externalizing behaviors
- Self-reported substance abuse
- Higher number of negative life events
- Lack of supervision
- Inconsistent discipline provided by caregivers

## 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.

## Conclusions: FAS and Delinquency

- 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