FETAL ALCOHOL
SPECTRUM DISORDERS
Tanya T. Nguyen
S D S U / U C S D J o i n t D o c to r a l P r o g r a m i n C l i n i c al P s yc h o l o g y
C e n te r f o r B e h av i o r a l Te r a to lo g y, S a n D i e g o S t a te U n i v e r s i t y
Drinking alcohol during pregnancy can have
permanent negative effects on the developing child.
 The mother’s blood alcohol level rises, and alcohol freely
crosses the placenta into the developing embryo or fetus.
 The developing child is being exposed to the same blood
alcohol levels as the mother.
FETAL ALCOHOL SYNDROME
 Prenatal alcohol exposure can
result in a wide range of
physical and neurobehavioral
problems.
Fetal Alcohol Syndrome (FAS)
 Growth deficiencies, either
prenatal or postnatal
 Permanent brain damage
 Abnormal facial features
(Photo courtesy of Teresa Kellerman)
FACIAL FEATURES
 Small palpebral fissures
 Smooth, indistinct philtrum
 Thin vermillion border
(Jones & Smith, 1975)
FAS IS ONLY THE TIP OF THE ICEBERG
Fetal alcohol spectrum
disorders (FASD)
 Umbrella term used to describe he
range of outcomes resulting from
alcohol exposure during pregnancy
 Not a diagnostic term
Death, SIDS, FAS
isolated effects;
problems with behavior
DIAGNOSTIC TERMS
 FAS
 Partial FAS (pFAS)
 Alcohol-related
neurodevelopmental disorder
(ARND)
 Alcohol-related birth defects
(ARBD)
FASD is not a diagnostic term
but is an umbrella term for
these various outcomes and
diagnoses.
FAS
pFAS
ARND
ARBD
BRAIN ABNORMALITIES
 Alcohol causes changes in
overall brain structure as
well as damage to
specific brain regions
 Central nervous system
dysfunction may be:
 Physical changes in the
brain
 Behavioral and cognitive
problems
BRAIN ABNORMALITIES
(Clarren, 1986)
Children with FASD also show reduced volume and
integrity in various regions of the brain
cerebral cortex: higher-order human cognition
(consciousness, attention, language, spatial
orientation, etc.)
hippocampus: formation of new
memories
basal ganglia: motor control, cognitive
and emotional functions
BRAIN ABNORMALITIES
BRAIN ABNORMALITIES
 Dif fusion Tensor
Imaging (DTI)
Corpus Callosum
 Decreased
integrity of white
matter
 Malformed,
underdeveloped
NORMAL
FASD
BRAIN ABNORMALITIES
 In addition to altered brain structure, prenatal alcohol
exposure is also associated with impaired brain function.
Children with FASD show greater brain activation in the frontal cor tex when
per forming the same level of task demands, compared to normal controls.
NORMAL
FASD
BEHAVIORAL DYSFUNCTION
Brain changes
Cognition & behavior
 Global brain
 Low intelligence
 Cerebral cortex
 Executive dysfunction
 Corpus callosum
 Cerebellum
 Learning & memory
problems
 Hippocampus
 Poor spatial abilities
 Basal ganglia
 Poor language development
 White & gray matter
development
 Reduced motor function
 Attention deficits &
hyperactivity
 Poor emotional regulation
and social cognition
GENERAL INTELLIGENCE
 The average IQ of individuals with prenatal alcohol exposure has
been repor ted as in the low 70’s for those with FAS and in the low
80’s for those without alcohol -related facial features.
Standard score
115
100
*
85
*
*
*
**
Normal
*
FASD (no facial features)
FAS
70
55
40
FSIQ
VIQ
IQ scale
PIQ
(Mattson et al., 1997)
LEARNING & MEMORY
 Children with and without the
facial features of FAS are
impaired in both learning and
memory of verbal and visual
information.
 Problems learning information
 Greater difficulty recalling and
recognizing information after a delay
EXECUTIVE FUNCTIONS
 Executive function is an
umbrella term for cognitive
processes that regulate,
control, and manage other
processes.








planning
problem solving
working memory
reasoning
inhibition
mental flexibility
multi-tasking
monitoring of actions
 Children with FASD show
deficit in all of these areas.
 Performance is characterized by
increased errors and more
difficulty adhering to rules.
MOTOR FUNCTION
 Children prenatally exposed to alcohol experience a
number of motor impairments in both gross and fine
motor skills:
 Poor hand-eye coordination
 Unstable balance
 Delayed reaction time
 Gait difficulties
 Slowed motor speed
 Poor force control
ATTENTION
 Greater than 60% of children with FASD have problems with
attention
 Parent and teacher reports of attention dif ficulties are
common.
 Higher rate of attention -deficit/hyperactive disorder (ADHD)
and hyperkinetic disorders.
 The nature of attention deficits in
FASD and ADHD dif fer:
 FASD: more difficulty with shifting
attention, encoding information, and
problem-solving
 ADHD: more difficulty with difficulties
focusing and sustaining attention
SECONDARY DISABILITIES
 Individuals with FASD suf fer from many physical, cognitive,
emotional, and social problems, which af fect daily functioning
and result in adverse life outcomes.
 Protective factors:
 Diagnosis before age 6
 Stable and nurturing
home environment
 No physical/sexual abuse
 Access to Developmental
Disabilities services
(Streissguth, et al., 1996, 2004)
IMPACT
 FASD is associated with significant social and economic
ramifications.
 $2 million: lifetime cost of a
single individual with FASD
 Over $3.6 billion: annual cost of
FAS in the U.S.
 Costs will continue to rise, as
the cost of medical treatment,
special education,
psychosocial interventions, and
residential care increases.
VARIABILIT Y OF OUTCOMES
 Not every woman who drinks heavily during pregnancy will
give birth to a child with an FASD
 Not all children with FASD have the same deficits
 Many biological and environmental factors influence the
ef fects of alcohol on the developing fetus
RISK FACTORS
 Many biological and environmental factors influence the
ef fects of alcohol on the developing fetus.
 Nature of alcohol exposure
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Level: amount of alcohol consumed
Duration: how long alcohol is consumed
Pattern: binge drinking is particularly dangerous to the fetus
Timing: drinking at different times during pregnancy affect different brain
areas that are developing
RISK FACTORS
 Many biological and environmental factors influence the
ef fects of alcohol on the developing fetus.
 Genetic background
 Certain genes affect the mother’s and child’s metabolism of and
sensitivity to alcohol
 May reduce the risk of alcohol’s effects on the brain
RISK FACTORS
 Many biological and environmental factors influence the
ef fects of alcohol on the developing fetus.
 Environmental factors
 Prenatal care & nutrition: alcohol exposure in combination with poor
nutrition increases risk for FASD
 Maternal age: risk of FASD increases with older maternal age and parity
 Socioeconomic status & race: incidence rates higher in low SES, African
American, and Native American communities
CONCEPTUAL FRAMEWORK
Alcohol
Consumption
During
Pregnancy
Embryonic
and Fetal
Development
Dose
Timing
Pattern
Genetics
Age
Nutrition
Brain
Environment
Genetics
Face
Behavior
PREVALENCE
FAS
General U.S.
Plain & Plateau tribes, U.S.
Canada
South Africa
Croatia
Italy
2-7 per 1000
9 per 1000
1-15 per 1000
46 per 1000
7 per 1000
4-7 per 1000
FASD
U.S. & Western Europe
South Africa
Italy
2-5%
7-9%
2-4%
(May et al., 2002, 2006, 2007, 2009; Petkovic & Barisic, 2010)
PREVENTION & INTERVENTION
 Despite known adverse consequences, public health warnings,
and other prevention ef forts, women continue to consume
alcohol during pregnancy
 7.6% of women in U.S. report drinking during pregnancy
 1.4% report binge patterns of drinking
 Women who have already given birth
to a child with FAS are at extremely
high-risk of having another af fected
child if they continue to abuse
alcohol.
PREVENTION
 Prevention framework that
provides a spectrum of
approaches
 3 levels of prevention:
 Universal prevention
 Selective prevention
 Indicated prevention
 As risk behaviors increase,
prevention measures become more
targeted and intensive.
PREVENTION
 Universal prevention – promote health of general public;
directed at all members of a particular group, regardless of
risk
 Supporting abstinence from alcohol use during pregnancy
 Raising awareness about FASD
 Implementing broad-based alcohol policy and environmental
strategies
 Increasing alcohol taxes
 Reducing alcohol consumption and excessive use
PREVENTION
 Selective prevention – directed at
women who may be of greater risk
 women of childbearing age who drink
alcohol
 Indicated prevention – aimed at
highest risk individuals
 high-risk drinkers (binge drinkers,
alcoholics)
 women currently pregnant and drinking
 women who have given birth to a child
with an FASD
ASSESSING FOR MATERNAL
CONSUMPTION
 Ask about:
 Alcohol consumption prior to pregnancy recognition AND after
pregnancy recognition
 Different types of alcohol separately
 Typical AND maximum level of consumption
INTERVENTIONS
 Currently, there is no single treatment that addresses all
problems related to FASD.
 Many children are treated for specific symptoms/problems
 Academic achievement and educational interventions
 Social and adaptive skills training
 Cognitive training
 Parent and caregiver interventions
provide education and support to families
 Improve parenting skills
 Increase parent self-efficacy
 Reduce strain on the parent-child relationship
MY THS ABOUT PREGNANCY & ALCOHOL
MY TH: Light drinking during pregnancy is not only OK but good.
 There is no known amount of alcohol that is safe to drink while
pregnant.
 To prevent FASDs, a woman should not drink alcohol while she is
pregnant, or even when she might get pregnant.
 FASD is 100% preventable.
MY THS ABOUT PREGNANCY & ALCOHOL
MY TH: Certain types of alcohol are safer for a pregnant woman
to drink than others.
 All drinks that contain alcohol can harm an unborn baby.
MY TH: It is OK to drink toward the end of pregnancy.
 There is no safe time to drink. Alcohol can harm a baby at any
point during pregnancy.
MY THS ABOUT PREGNANCY & ALCOHOL
MY TH: Only women who have drinking problems have babies
with FASD.
 ANY exposure to alcohol could cause damage to the
developing baby.
 Many women are 2-3 months along before they know they are
expecting and may drink alcohol when they are not even
aware that they are pregnant.
MY THS ABOUT PREGNANCY & ALCOHOL
MY TH: Don’t worry, your child will outgrow any problems caused
by drinking during pregnancy.
 The damage caused by prenatal alcohol exposure is permanent and
last a lifetime.
 Symptoms may var y with age and with inter ventions, but the
problems associated with FASD are long -lasting.
RESOURCES
 National
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NOFAS (http://www.nofas.org/)
FAS Family Resource Institute (http://www.fetalalcoholsyndrome.org /)
FASD Center for Excellence (http://fasdcenter.samhsa.gov/)
FASD Internet Support Groups (http://www.come-over.to/FAS/fasonline.htm)
 San Diego
 FASD Clinic at Rady Children’s Hospital San Diego (http://ctispregnancy.org)
THANK YOU
Any questions?